New York State 
                                                                         Department of State 
                                                               DIVISION OF CORPORATIONS, 
                                                                         STATE RECORDS AND  
                                                               UNIFORM COMMERCIAL CODE 
                                                                         One Commerce Plaza 
                                                                         99 Washington Ave. 
                                                                         Albany, NY 12231-0001 
                                                                         https://dos.ny.gov                                         
DOCUMENT AND CERTIFICATE COVER SHEET 

Contact Information 
 
Name:   ______________________________________________________________________________ 
 
Mailing Address:_______________________________________________________________________ 
                   
              _____________________________________________________________________________ 
 
Email Address: ______________________________________________________________________ 
 
Phone Number:  ______________________________________________________________________ 
 
Request for Filing of Document 
 
Exact Name of Entity: __________________________________________________________ 
____________________________________________________________ 
 
Document Type:_______________________________________________________________  
                                   (i.e., Certificate of Incorporation, Articles of Organization, Certificate of Amendment, etc.): 
 
Request for Copies or Certificates of Status (Check the appropriate box) 
 
Exact Name of Entity: __________________________________________________________ 

□ Certified Copies of all Documents on File ($10 per document) 

□ Plain Copies of all Documents on File ($5 per document) 

□Certified Copy of _____________________________________________________ ($10 per document) 
                               (specify document) 

□ Plain Copy of ________________________________________________________ ($5 per document) 
                               (specify document) 

□ Certificate of Status - Long Form ($25 per document) 

□ Certificate of Status - Short Form ($25 per document)   
 
Method of Delivery of Filing Receipt or Other Document  

All documents will be returned to the email address listed above with the exception of certified and 
uncertified copies filed before July 1990. 

DOS-2183-f (04/22) 

                                                                                                     New York State 
                                                                                                     Department of State 
                                                                                                     DIVISION OF CORPORATIONS, 
                                                                                                     STATE RECORDS AND  
                                                                                                     UNIFORM COMMERCIAL CODE 
                                                                                                     One Commerce Plaza 
                                                                                                     99 Washington Ave. 
                                                                                                     Albany, NY 12231-0001 
                                                                                                     https://dos.ny.gov 

                             APPLICATION FOR AUTHORITY 

                                                               OF 
 
                             (Insert name of Foreign Professional Service Limited Liability Company) 

                             Under Section 1306 of the Limited Liability Company Law 

 FIRST: The name of the foreign professional service limited liability company is: 
  
                                                                                                                                                                                . 
 The name of the foreign professional service limited liability company does not end with the required 
 words or abbreviation pursuant to Section 1306(a)(1) of the Limited Liability Company Law, the following 
 words or abbreviation is added to the end of its name for use in this state is: 

                                                                                                                                                                                 .                                                                                                                                                            

 SECOND: The jurisdiction of organization of the foreign professional service limited liability company 
 is:                                                                                                                                                                         . 
   
 The date of its formation is:                                                                                                                                . 
   
 THIRD: The foreign professional service limited liability company shall practice the profession(s) of                                
                                                                                                                                                                              
 in the State of New York. 
   
 FOURTH: The foreign professional service limited liability company is authorized to practice such 
 profession(s) in the jurisdiction of its formation. 
  
 FIFTH: The city, incorporated village or town and the county within New York State in which its office is 

 to be located is:                                                                                                                                                   .                                                                                                                                             
 (A city, incorporated village or town and county in New York State must be stated.  Please note that the foreign limited liability 
 company  is not required to have an actual physical office in this state.) 

 DOS-1369-f-a  (Rev. 12/22)                                                                              Page 1 of 3 

 SIXTH:  The Secretary of State is designated as agent of the foreign professional service limited liability 
 company upon whom process against the foreign professional service limited liability company may be 
 served. 
         The post office address to which the Secretary of State shall mail a copy of any process against the 
         foreign professional service limited liability company served upon the Secretary of State by 
         personal delivery is: 
   
                                                                                                                                                                            . 
         (Optional) The email address to which the Secretary of State shall email a notice of the fact that 
         process against the foreign professional service limited liability company has been served 
         electronically upon the Secretary of State is: 
  
 SEVENTH: The name and address and, where applicable, the New York State license number of each 
 professional within the foreign professional service limited liability company who is licensed to practice the 
 profession or professions in New York State is: 
  
                                                                                                                                                                            . 
 
 X                                                                                      Capacity of signer (Check appropriate box):  
                       (Signature) 
 
                                                                                              Member 
 
                                                              (Type or print name)      Manager 
                                                                                        Authorized Person   

 DOS-1369-f-a  (Rev. 12/22)                                                                                                              Page 2 of 3 

                                    APPLICATION FOR AUTHORITY  
                                                               OF 
 
                                   (Insert name of Foreign Professional Service Limited Liability Company) 
 
                            Under Section 1306 of the Limited Liability Company Law 
 
     Filer’s Name and Mailing Address: 

         Name: 

         Company, if Applicable: 

         Mailing Address: 

         City, State and Zip Code: 
  
 NOTES:  
 1. This form was prepared by the New York State Department of State for filing an application for authority by a foreign  
    professional service limited liability company. It does not contain all optional provisions under the law. You are not required  
    to use this form. You may draft your own form or use forms available at legal supply stores. 
 2. Attach a Certificate of Existence, Certificate of Good Standing or Certificate of Status from the official who files and maintains  
     limited liability company records in the jurisdiction of the foreign professional limited liability company’s formation. 
 3. The name of the foreign professional limited liability company and its date of formation provided on this document must  
     exactly match the name of the foreign professional limited liability company and, if applicable, the date of formation stated in 
     the Certificate of Existence, Certificate of Good Standing or Certificate of Status. 
 4. A certificate of Good Standing from the appropriate Appellate Division or a Certificate of Authority (Form PLS709) under seal  
     from the New York State Department of Education, Division of Professional Licensing Services, Corporations Unit, 89  
     Washington Avenue, 2 ndFloor, Albany, NY 12234, must be submitted with the Application for Authority. 
 5. The Department of State recommends that legal documents be prepared under the guidance of an attorney.  
 6. The application for authority must be submitted with a $200 filing fee made payable to the Department of State. 
   
 (For office use only) 
 
 DOS-1369-f-a  (Rev. 12/22)                                                                                                       Page 3 of 3