State of Alaska Division of Corporations, Business and Professional Licensing CORPORATIONS SECTION PO Box 110806 Juneau, AK 99811-0806 Phone: (907) 465-2550 Fax: (907) 465-2974 Website: www.commerce.state.ak.us/occ BUSINESS NAME REGISTRATION APPLICATION DO NOT STAMP ABOVE THIS BOX CORP (OFFICE USE ONLY) Check if this is a renewal application FULL BUSINESS NAME: “Assumed Names” or “Fictitious Names” are referred to in Alaska as DBA Names. If the owner is a corporate entity, and is registering the name as a DBA name, list the name and principal office address of the entity. NAME AND ADDRESS OF BUSINESS OWNER: Name Mailing Address City, State, Zip NAME AND ADDRESS OF THE BUSINESS: Name Mailing Address City, State, Zip ADDITIONAL PERSONS THAT HAVE AN INTEREST IN THE BUSINESS: Name Mailing Address City, State, Zip The nature of the business is: Pursuant to AS 43.70.020, for the privilege of engaging in a business in the state, a person must first obtain a business license. Business License Number The signer acknowledges that the business is in operation. The signer must be an owner of the business, or an authorized person of the DBA entity. Signature Title Date Contact Name and Phone Number (to resolve questions with this filing) Mail the completed form and the $25.00 non-refundable filing fee in U.S. Funds to: State of Alaska Corporations Section PO Box 110806 Juneau, AK 99811-0806 08-575 (Rev. 10/2010) American LegalNet, Inc. www.FormsWorkFlow.com