CONDUCT OF BUSINESS UNDER FICTITIOUS OR ASSUMED NAMED

Date:  ___________________

To:  ____________________________________________

State of:  ___________________

Pursuant to _________________, relating to the conduct of business under ___________________ name, the undersigned, hereby present(s) for filing the following application in the office of:

1. The name under which the business is, or will be, carried on is:

2. The real name and address of each person owning or interested in the business is:

3. The nature of the business is:

4. The business will be conducted at:

STATE OF ___________________

COUNTY OF _________________

On____________________before me,______________________, personally appeared ______________________________________________, personally known to me (or proved
to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

WITNESS my hand and official seal.

Signature______________________________

Affiant _____Known _____Unknown

ID Produced______________________

(Seal)
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