Oregon Department of Consumer & Business Services Division of Finance & Corporate Securities 350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881 Mailing address: P.O. Box 14480, Salem, OR 97309-0405 (503) 378-4140 Fax: (503) 947-7862 TTY: (503) 378-4100 http://dfcs.oregon.gov CHANGE OF NAME OR ADDRESS REQUEST Current license name: ML: DBA/ABN: Type of change request: Name change applies to: Company name Add DBA/ABN Remove DBA/ABN Address change applies to: Primary location Branch # location New information: Effective date of change: Final license name: ML: Final DBA/ABN: Location address: City: State: ZIP: Mailing address (if different): City: State: ZIP: Phone numbers: Remains the same New numbers Telephone: ( ) - Fax: ( ) - Toll free: ( ) - E-mail: Contact name: Title: Phone number:( ) - Check list of other documentation needs: Rider to surety bond showing final name or address after change. Copies of Oregon business registry change request of name or address. Copies of changed licenses in state of primary location (other than Ore gon). Transmittal (cover) letter describing change and signed by authorized representative. Disclosure of Significant Developments [OAR 441-860-0070(1)] A licensee shall be required to notify the Director within 30 days of the occurrence of any ... significant developments. American LegalNet, Inc. www.USCourtForms.com Change of name or address request440-3919 (7/04/COM/WEB) Page 1 of 1