State of Missouri Corporations Division PO Box 778 / 600 W. Main St., Rm. 322 Jefferson City, MO 65102 John R. Ashcroft, Secretary of State This information is for the use of the public and gives no protection to the name being registered. There is no provision in this Chapter to keep another person or business entity from adopting and using the same name. The fictitious name registration expires 5 years from the filing date. (Chapter 417, RSMo) Please check one box: The undersigned is doing business under the following name and at the following address: Business name to be registered: Business Address: City, State and Zip Code: Owner Information: (PO Box may only be used in addition to a physical street address) Registration of Fictitious Name (Submit with filing fee of $7.00) (Must be typed or printed) New Registration Renewal _______________ X Charter number Amendment X _______________ Charter number Correction X _______________ Charter number If a business entity is an owner, indicate business name and percentage owned. If all parties are jointly and severally liable, percentage of ownership need not be listed. Please attach a separate page for more than three owners. The parties having an interest in the business, and the percentage they own are: Name of Owners, Individual or Business Entity Charter # Required If Business Entity Street and Number City and State Zip Code If Listed, Percentage of Ownership Must Equal 100% All owners must affirm by signing below In Affirmation thereof, the facts stated above are true and correct: Owner's Signature or Authorized Signature of Business Entity Owner's Signature or Authorized Signature of Business Entity Owner's Signature or Authorized Signature of Business Entity (The undersigned understands that false statements made in this filing are subject to the penalties of a false declaration under Section 575.060 RSMo) Printed Name Printed Name Printed Name Date Date Date Name and address to return filed document: Name: Address: City, State, and Zip Code: Corp. 56 (01/2017) American LegalNet, Inc. www.FormsWorkFlow.com