This space reserved for office use. | |||||||||||
Form 201 (Revised 12/21) Submit in duplicate to: Secretary of State P.O. Box 13697 Austin, TX 78711-3697 512 463-5555 Filing Fee: $300 | ![]() Certificate of Formation For-Profit Corporation |
Black Rock Coffee Bar, Inc. | |||||
CT Corporation System |
First Name | M.I. | Last Name | Suffix |
1999 Bryan Street, Suite 900 | Dallas | TX | 75201 | |||||||||||
Street Address | City | State | Zip Code |
Director 1 | |||||||||||||||||||||||
Daniel | Brand | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
Form 201 | 1 |
Director 2 | |||||||||||||||||||||||
Andrew | Braithwaite | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
Director 3 | |||||||||||||||||||||||
Mark | Davis | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
Director 4 | |||||||||||||||||||||||
Richard | Federico | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
Director 5 | |||||||||||||||||||||||
Sarah | Grover | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
Director 6 | |||||||||||||||||||||||
Jeffrey | Hernandez | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
Form 201 | 2 |
Director 7 | |||||||||||||||||||||||
Bryan | Pereboom | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
Director 8 | |||||||||||||||||||||||
Jake | Spellmeyer | ||||||||||||||||||||||
First Name | M.I. | Last Name | Suffix | ||||||||||||||||||||
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | |||||||||||||||||||
Street or Mailing Address | City | State | Zip Code | Country |
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | USA | ||||||||||||||||||||||
Mailing Address | City | State | Zip Code | Country |
Form 201 | 3 |
Text Area: [The attached addendum, if any, is incorporated herein by reference.] | |||||
The Certificate of Formation of Black Rock Coffee Bar, Inc., filed as part of the conversion of Black Rock Coffee Bar, Inc. (the “Converting Entity”), reflects that the entity was formed pursuant to a plan of conversion in accordance with Section 3.005(a)(8) of the Texas Business Organizations Code. The Converting Entity was Black Rock Coffee Bar, Inc., a corporation formed under the laws of the State of Delaware, and located at 9170 E. Bahia Drive, Suite 101, Scottsdale, AZ 85260. The original date of formation of the Converting Entity was May 2, 2025. Where any of this information is not explicitly stated in the Certificate of Formation, it is included in the plan of conversion or is otherwise publicly available through the records of the applicable Secretary of State or similar office. |
Samuel Seiberling | |||||
Name |
9170 E. Bahia Drive, Suite 101 | Scottsdale | AZ | 85260 | ||||||||||||||
Street or Mailing Address | City | State | Zip Code |
Form 201 | 4 |
Date: | June 23, 2025 | |||||||||||||
/s/ Samuel Seiberling | ||||||||||||||
Signature of organizer | ||||||||||||||
Samuel Seiberling | ||||||||||||||
Printed or typed name of organizer |
Form 201 | 5 |