Arkansas Secretary of State Mark Martin 1401 W. Capitol, Suite 250, Little Rock, AR 72201 501-682-3409 · www.sos.arkansas.gov INSTRUCTIONS: File with the Secretary of State's Office, Business Services Division, State Capitol, Little Rock, Arkansas 72201-1094. A copy will be returned to the entity and must be filed with the County Clerk in the county in which the entity's registered office is located (unless registered office is in Pulaski County). APPLICATION FOR FICTITIOUS NAME Select entity type: For-Profit Corporation ($25.00 fee) General Partnership ($15.00 fee) LLC ($25.00 fee) LLLP ($15.00 fee) Nonprofit Corporation ($25.00 fee) Limited Partnership ($15.00 fee) LLP ($15.00 fee) (Make Checks Payable To: Arkansas Secretary of State) Pursuant to the provisions of Arkansas law, the undersigned entity hereby applies for the use of a fictitious name and submits herewith the following statement: 1. The fictitious name under which the business is being, or will be, conducted by this entity is: ________________________________________________________________________________ 2. The character of the business being, or to be, conducted under such fictitious name is: ________________________________________________________________________________ 3. a) The entity name of the applicant and its date of qualification in Arkansas: Date: _______________ Name: ___________________________________________________________________________ b) The entity is Domestic Foreign (state of domestic registration) ________________ c) The location (city and street address) of the registered office of the applicant entity in Arkansas is: _________________________ _________________________ __________ Street City State ______________ ZIP Code I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days. Authorizing Officer _________________________________________________________________ (Type or Print) Authorized Signature: ______________________________________________________________ (Chairman, Partner or other authorized person) Address: _________________________________________________________________________ DN-18/F-18 Rev. 08/15 American LegalNet, Inc. www.FormsWorkFlow.com