APPLICATION FOR REGISTRATION OF FICTITIOUS NAME Note: Acknowledgments/certificates will be sent to the address in Section 1 only. This space for office use only Mark the applicable boxes Certificate of Status - $10 Certified Copy - $30NON-REFUNDABLE PROCESSING FEE: $50 CR4E001 (1/17) 1. Fictitious Name to be Registered (see instructions for certain prohibited words, abbreviations and designations) 2. Mailing Address of Business City State Zip 3.Florida County of principal place of business: (see instructions if more than one county)4.FEI Number of Business: Section 1 A. Registrant i f i ndividual(s): (Use an attachment if necessary): 1. 2. Last First M.I. Last First M.I. Address Address City State Zip City State Zip B.Registrant if other than an individual(s): (Use an attachment if necessary): 2. Entity Name Entity Name Address Address City State Zip City State Zip Florida Document Number: Florida Document Number: FEI Number: FEI Number: Applied for Not Applicable Applied for Not Applicable Section 2 Section 3 I the undersigned, being a registrant for the above fictitious name, certify that the information indicated on this form is true and accurate. In accordance with Section 865.09, F.S., I further certify that the intention to register the fictitious name to be registered has been advertised at least once in a newspaper as defined in chapter 50, Florida Statutes, in the county in which the principal place of business of the registrant is or will be located. I understand that the signature below shall have the same legal effect as if made under oath and I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s.817.155, F.S. Signature of Registrant in Section 2 Date Email address: (to be used for future renewal notifications) FOR CANCELLATIONS, COMPLETE THIS SECTION 4 ONLY: FOR FICTITIOUS NAME REGISTRATION CHANGE, COMPLETE SECTIONS 1 THROUGH 4: I (we) the undersigned, hereby cancel the fictitious name , which was registered on and assigned registration number . Signature of Registrant Whose Registration is Being Cancelled Date Signature of Registrant Whose Registration is Being Cancelled Date Section 4 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Application for Registration of Fictitious Name Section 1: Line 1: Enter the name as you wish it to be registered. A fictitious name may not contain words, abbreviations or designations that comprise a business entity suffix or indicator (e.g., 223Corporation,224 223Incorporated,224 223Professional Association,224 223Limited Liability Company,224 223Professional Limited Liability Company,224 223Limited Liability Partnership,224 223Limited Partnership,224 223Corp.,224 223Inc.,224 223P.A.,224 223L.L.C.,224 223P.L.L.C.,224 223L.L.P.,224 223L.P.,224 etc.) unless the person or business for which the name is registered is a business entity of the same type duly incorporated, organized, formed or registered in Florida or otherwise authorized to transact business in Florida. Business entities are not required to file under their exact entity name. Section 655.922, Florida Statutes, prohibits anyone other than financial institutions to use the word(s) "bank," "banc," "banco," 'banque," "banker," "trust company," "savings and loan association," "savings bank," or "credit union," or words of similar import. Line 2: Enter the mailing address of the business. This address does not have to be the principal place of business and can be directed to anyone222s attention. DO NOT USE AN ADDRESS THAT IS NOT YET OCCUPIED. ALL FUTURE MAILINGS AND ANY CERTIFICATION REQUESTED ON THIS REGISTRATION FORM WILL BE SENT TO THE ADDRESS IN SECTION 1. An address may be changed at any future date with no charge by simply writing the Division. Line 3: Enter the name of the county in Florida where the principal place of business of the fictitious name is located. If there is more than one county, list all applicable counties or state 223multiple224. Line 4: Enter the Federal Employer Identification (FEI) number if known or if applicable. Please do not enter your social security number. Section 2: Part A: Complete if the registrant(s) of the fictitious name are individuals. The individual222s name and address must be provided. Part B: Complete if the registrant (s) are not individuals. Examples are a corporation, limited liability company, limited partnership, joint venture, general partnership, trusts, etc. Provide the name of the registrant(s), their address(es), their document number(s) as registered with the Division of Corporations, and the Federal Employer Identification (FEI) number. An FEI number must be provided for each registrant or the appropriate box must be checked. Registrants listed in Part B must be registered with the Division of Corporations or provide documentation as to why they are not required to register. Examples would be Federally Chartered Corporations, or Legislatively created entities. With respect to a general partnership that is not registered with the Division of Corporations, its partners are the registrants and not the partnership entity. With respect to a general partnership that is registered with the Division of Corporations, the partnership is the registrant. In order for the fictitious name registration to be filed, each entity that is a registrant must be in active status with the Division of Corporations at the time the fictitious name registration is filed. Additional registrants may be listed on an attached page as long as all of the information requested in Part A or Part B is provided. Section 3: Signature of the registrant is required. It is preferred that a daytime phone number be provided in order to contact the registrant if there are any questions about the application. Section 4: TO CANCEL A REGISTRATION ON FILE: Provide fictitious name, date filed, and registration number of the fictitious name to be cancelled. A registrant222s signature is required for cancellation. TO CHANGE A REGISTRATION: Complete section 4 to cancel the original registration. Complete sections 1 through 3 to re-register the fictitious name listing the new registrant(s). A registrant222s signature is required in both sections 3 and 4. TO CHANGE THE NAME OF A REGISTRATION: Complete section 4 to cancel the original registration. Complete sections 1 through 3 to re-register the new fictitious name. A registrant222s signature is required in both sections 3 and 4. An acknowledgement letter will be mailed when the fictitious name registration has been filed. The acknowledgement letter and any certification requested will be mailed to the address provided in Section 1. For Cancellations Only: please provide a mailing address on an attachment, if the address on our records is no longer valid. To request a certificate of status and/or certified copy, please check the appropriate box(es) and include the additional fee(s) ($10 for a certificate of status, $30 for a certified copy). A registration or a reregistration will be in effect until December 31 of the fifth calendar year, thereafter. Send completed application with appropriate fees to: The fee for registering a fictitious name is $50. Please make a separate check for each filing payable to the Department of State. Application must be typed or printed in ink and legible. Single CR4E001 (1/17) Fictitious Name Registration PO Box 6327 Tallahassee, FL 32314 Internet Address: http://www.sunbiz.org Courier Address Division of Corporations Clifton Building 2661 Executive Center Circle Tallahassee, FL 32301 American LegalNet, Inc. www.FormsWorkFlow.com