Statutory Agent Acceptance Form

Statutory Agent Acceptance Form
Complete this form to designate and accept a statutory agent for your business entity.
Business Entity Name
Business Entity Type
Statutory Agent Full Name
First NameLast Name
Statutory Agent Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Statutory Agent Email
example@example.com
Statutory Agent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Acceptance
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Statutory Agent Signature
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Should be Empty: