Form 3804 Rev. 04/2016 This space reserved for office use only Submit to: SECRETARY OF STATE Registrations Unit P O Box 13193 Austin, TX 78711-3193 512-475-0775 DENTAL SUPPORT ORGANIZATION BUSINESS SUPPORT SERVICES ADDENDUM Include with the Dental Support Organization Registration when number of dentists exceeds space provided. Dentist Name: Name of Professional Entity or Dental Practice: Business Address (Please include street address, city, state and zip code): Describe all business support services provided: Dentist Name: Name of Professional Entity or Dental Practice: Business Address (Please include street address, city, state and zip code): Describe all business support services provided: Dentist Name: Name of Professional Entity or Dental Practice: Business Address (Please include street address, city, state and zip code): Describe all business support services provided: American LegalNet, Inc. www.FormsWorkFlow.com