Form 3803 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 OWNERSHIP INFORMATION ADDENDUM Dentist Owner: Non-Dentist Owner: Include with the Dental Support Organization Registration when number of owners exceeds space provided. Name: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): American LegalNet, Inc. www.FormsWorkFlow.com