Request for Certificate 
             Secretary of State - Corporation Division - 255 Capitol St. NE, Suite 151 - Salem, OR 97310-1327 - sos.oregon.gov/business - Phone: (503) 986-2200 

                                      Copy Request Fax:             503-378-6520 

REQUESTER INFORMATION: 
Name of Requester: 

Mailing Address:  (Street Address or PO Box)                       (City, State)                                                       (Zip Code) 

Area Code and Phone Number: 

ENTITY NAME/REGISTRY NUMBER: Information is located at http://sos.oregon.gov/bizsearch 

Entity Name:                                                                     Registry Number: 

CERTIFICATE ATTESTING TO: 

 STATUS/EXISTENCE - $10               MERGER - $10                  NAME CHANGE - $10                            NO RECORD - $10 

For more information about the certificates that we provide, visit http://sos.oregon.gov/business/Pages/business-registry-certificates.aspx 

 If document is going out of the Country: (Additional $10 for Authentication)    What Country? 

DELIVERY: Choose Delivery Option(s)   (Please note: There is a separate charge per delivery.) 
 Pick up in person.               Mail to above address. 

 Fax: (USA Only - Area Code & Fax Number) 
For all overnight/express service delivery, a prepaid airbill must be provided. 

METHOD OF PAYMENT: 
  Check/Money order is included. (Make payable to Corporation Division.) 
  MasterCard                     VISA         Discover
 CREDIT CARD NUMBER:            

  American Express 

 CREDIT CARD NUMBER: 

 Expiration Date: 

 Cardholder Name: 

 Billing Address: 

 City, State, Zip Code: 

 Phone Number: 
Request for Certificate (8/22)