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KANSAS SECRETARY OF STATE

Nonresident Contractors Appointment of Service Agent

All information must be completed or this document will not be accepted for filing.

1.	hereby

(Name of individual, partnership, association or corporation)

appoints for three years:

(Name of service agent – must be Kansas resident)

2. The address of the service agent in Kansas is: (Address must be a street address. A post office box is unacceptable)

Street address City State Zip

3. The state in which the company was formed:

4. The company mailing address is:

Street address City State Zip

5. In testimony whereof, I,	, of said entity,

hereunto subscribe my name this	day of	,	.

Day Month Year

Signature

State of

County of

Acknowledged before me this	day of	,	.

My appointment or commission expires	.

Affix an impression of notary’s seal here:

Notary’s Signature

Project Name

Rev. 9/22/03 amt	ASA–1	K.S.A. 56a-1001,1102

Do not write in this space

Instruction

Note: Nonresident contractors under K.S.A. 16-113 who are foreign corporations, foreign limited partnerships or foreign liability companies qualified to do business and in good standing in Kansas are not required to file this form.

1.	Please submit this form properly notarized with the $35 filing fee.

Notice: There is a $25 service fee for all returned checks.

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Contact Information

Kansas Secretary of State

Ron Thornburgh

Memorial Hall, 1st Floor

120 S.W. 10th Avenue

Topeka, KS 66612-1594

(785) 296-4564

kssos@kssos.org

www.kssos.org

COP 211 - Appointment of Service Agent

Public Works

2010-08-04

Mary Lou McClanahan

City of Overland Park