State of Utah Department of Commerce Division of Corporations & Commercial Code Business Name Registration / DBA Application WARNING: The filing of this application and its approval by the Division does not authorize the use in the state of Utah of an assumed name in violation of the rights of another under federal, state, or common law (U.C.A. Section 42-2-5 Et seq.). *When approved the DBA is registered for 3 years. *If adding or removing an Applicant/Owner, which will affect its status as a General Partnership or Sole Proprietorship, you must submit a Registration Information Change Form. *If you want a new name (adding or changing the existing name), a new DBA filing is required. Non-Refundable Processing Fee: [ Requested Business Name: ] New Filing $22.00 [ ] Applicant/Owner Transfer N/A Business Purpose: Business Address: ______________________________________________________________________ Zip Address City State Who/What is the name of the Registered Agent (Individual or Business Entity or Commercial Registered Agent)?: ________________________________________________________________________________________ The address must be listed if you have a non-commercial registered agent. See instructions for further details. Address of the Registered Agent: ___________________________________________________________ Utah Street Address Required, PO Boxes can be listed after the Street Address City: State UT Zip: Applicant/Owner: List the individual or business entity that will own the DBA on the name line. (The registered agent will be recorded as the applicant/owner if this section is left blank) Name: _______________________________________________________________________________ Entity Number (if a registered business): ____________________________________________________ Address: _____________________________________________________________________________ City: __________________________________________________ State: ________ Zip: ____________ Under penalties of perjury, I declare that this DBA Application has been examined by me and is, to the best of my knowledge and belief, true, correct and complete. Signature: Applicant/Owner: List the individual or business entity that will own the DBA on the name line. Name: _______________________________________________________________________________ Entity Number (if a registered business): ____________________________________________________ Address: _____________________________________________________________________________ City: __________________________________________________ State: ________ Zip: ____________ Under penalties of perjury, I declare that this DBA Application has been examined by me and is, to the best of my knowledge and belief, true, correct and complete. If needed, you may use an attached sheet for additional applicants Signature: Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity. Optional Inclusion of Ownership Information: This information is not required. Is this a female owned business? Yes No Is this a minority owned business? Yes No If yes, please specify: Mailing/Faxing Information: www.corporations.utah.gov/contactus.html Division's Website: www.corporations.utah.gov 01/14 American LegalNet, Inc. www.FormsWorkFlow.com