TRADE NAME OR ASSUMED BUSINESS NAME FILING 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 www.oregondfcs.org Pursuant to ORS 59.175(7) and OAR 441-175-0171 Date: Applicants CRD number: Trade name or assumed business name: Applicants name: Business address: City, State, ZIP: Contacts name: Phone number: ( ) Fax: ( ) Signature: Print name: Title (if applicable): Visa MasterCard Filing fee: $50 Credit card number Expiration date Make check or money order payable to Department of Consumer & Business Services. If paying by credit Name of cardholder as shown on credit card card, applicant must sign credit-card information box. Mail application with payment to: $ Cardholder signature Amount DCBS Fiscal Services P.O. Box 14610 Salem, OR 97309-0405 Fiscal use only: 62110/1002 $50.00 440-2774 (4/03/COM/WEB) American LegalNet, Inc. www.USCourtForms.com