Arkansas Secre t a ry of State State Capitol • Little Rock, Arkansas 72201-1094 501-682-3409 • www.sos.arkansas.gov Charlie Daniels 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) 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: ____________________ ___________________________________________________________________________ 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: _________________________________________________________________________ Fee: see top of page DN-18/F-18/Rev. 4/06 American LegalNet, Inc. www.FormsWorkflow.com