Order Entry

               

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Revision to Statutory Representation            

1. COMPANY NAME AND ADDRESS
Company Name
Address
City State OR Province
Country Zip/Postal Code
Telephone
Fax
2. COUNSEL NAME AND ADDRESS
Counsel Name
Address
City State OR Province
Country Zip/Postal Code
Telephone
Fax
3. PARENT COMPANY NAME (If applicable)
4. State of Inc.  5. Date of Incorporation  6. Fiscal Year End  7. Federal ID. # 

ACTION

a. CHANGE OF NAME


(ENTER NEW COMPANY NAME):
b. CHANGE OF EXISTING NAME AND/OR ADDRESS (COMPANY OR COUNSEL): c. CHANGE OF COMMUNICATIONS:

Communications

8. Service of Process Address
Same as Company
Same as Counsel
Use the Address Below
Company Name
Address
Attention
City State OR Province
Country Zip/Postal Code
Telephone
Fax
9. Tax & Routine Communications
Same as Company
Same as Counsel
Use the Address Below
Company Name
Address
Attention
City State OR Province
Country Zip/Postal Code
Telephone
Fax
10. Renewal Invoicing Address
Same as Company
Same as Counsel
Use the Address Below
Company Name
Address
Attention
City State OR Province
Country Zip/Postal Code
Telephone
Fax

PLEASE ATTACH SEPARATE RIDER FOR SPECIAL INSTRUCTIONS FOR SERVICE OF PROCESS

GENERAL COMMENTS OR INSTRUCTIONS:
Affiliate Employee & Origination Office: Date: