FILING FEE: N/AFILE ONE ORIGINAL (Two if you want a filed stamped copy returned to you.)1.The name of the business applyingto register a Trade Name (DBA) is:2.The above business is applying to do business within West Virginia under the following Trade Name (DBA) [If more than oneTrade Name (DBA) is being registered, list each name being registered on a separate line below.]: 3.List the full name(s) and address(es) of the person or persons having signature authority to make the application per WV Code24747-8-2 . [NOTE: If the business is a General Partnership, ALL PARTNERS must be listed under this section and eachpartner must sign this application under item #4 below. Continued on page 2. Attach additional pages if more than fourpartners are listed on the general partnership]: **** The undersigned, having authority to execute this application, duly acknowledges compliance to register the trade name **** for the registered business below according to West Virginia Code 24747-8-2; 3 . If your organization is registered as a Corporation, Limited Liability Company, Limited Partnership, Limited Liability Partnership, Voluntary Association or Business Trust, DO NOT complete this form. You must file Form NR-3 to register a Trade Name (DBA). City/State/Zip:Address 1:Name 1:Address 2: City/State/Zip:Address 2:Address 1:Name 2: City/State/Zip:Address 2:Address 1:Name 3: a.Trade Name (DBA): b.Trade Name (DBA): c.Trade Name (DBA): d.Trade Name (DBA):Continued on page 2.TRADE NAME (DBA) REGISTRATION (Form for Individual, Sole Proprietorship and General Partnership registered through West Virginia State Tax Department.)Form TN-1 Rev. 11/2017West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov TRADE NAME (DBA) REGISTRATIONPage 2 Important Note: This form is a public document. Please DO NOT provide any personal identifiable information on this form such as social security number, bank account numbers, credit card numbers, tax identification or driver222s license numbers. Date: Title: Signature: Date: Title: Signature: Date: Title: Signature: Contact Phone #: Contact Person Name:4.Contact and Signature Information: Individual or Sole Proprietorship - Provide only one signature in the space below. General Partnership - Provide signatures of ALL general partners listed above under item #3. Date: Title: Signature: Contact E-mail:Enter in the spaces below the contact information of the person to reach in case there is a problem with the application. City/State/Zip: Address 2: Address 1: Name 4:3.Continued from page 1. (Form for Individual, Sole Proprietorship and General Partnership registered through West Virginia State Tax Department.) CHOOSE ONE OF THE FOLLOWING PROCESSING SERVICES: 1 EXPEDITED SERVICE (24-hour, 2-hour and 1-hour; *Requires standard filing fee plus additional expedite fee, see below) West Virginia Secretary of State Business & Licensing Division Tel: (304) 558-8000 Fax: (304) 558-8381 Website: www.wvsos.gov Filing Submission Instructions - Business DivisionSUBMIT THE COMPLETED APPLICATION WITH THE CUSTOMER ORDER REQUEST FORM TO ONE OF THE OFFICES BELOW. CHOOSE EXPEDITED OR STANDARD PROCESSING SERVICE. IF NOT USING THE CUSTOMER ORDER REQUEST FORM AND YOU ARE REQUESTING EXPEDITED SERVICE, YOU MUST INCLUDE THE WORD "EXPEDITE" AND THE LEVEL OF EXPEDITED SERVICE BEING REQUESTED (24-HOUR, 2-HOUR OR 1-HOUR) IN YOUR CORRESPONDENCE. BE SURE TO INCLUDE THE CORRECT ADDITIONAL EXPEDITED FEE. THIS FEE IS IN ADDITION TO THE REGULAR FILING FEE (SEE FEES BELOW).BUSINESS SERVICE CENTERS Standard and Expedited Filings Charleston Office One-Stop Business Center 1615 Washington Street East Charleston, WV 25311 Phone: (304) 558-8000 Fax: (304) 558-8381 Hours: Mon. - Fri. 8:30a - 5:00p EST Clarksburg Office North Central WV Business Center 200 West Main Street Clarksburg, WV 26301 Phone: (304) 367-2775 Fax: (304) 627-2243 Hours: Mon. -Fri. 9:00a - 5:00p EST Martinsburg Office Eastern Panhandle Business Center 229 E. Martin Street Martinsburg, WV 25401 Phone: TBA Fax: TBA Hours: Mon. - Fri. 9:00a - 5:00p ESTIMPORTANT: READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORMS. Please follow the instructions included with the application. Failure to include any of the required information on the form may cause the filing to be rejected.All forms may be downloaded from our web site www.wvsos.gov . Rev. 11/2017 *Fee$ 25.00 $250.00 $500.00 Expedite Service 24-Hour 2-Hour 1-HourEXPEDITED SERVICE requests may be submitted by: - E-mail to efilings@wvsos.gov - Fax - Walk in delivery 2 STANDARD PROCESSING (5-10 business days) SUBMIT COMPLETED FILING TO ONE OF THE BUSINESS CENTERS BELOW: INCLUDE PAYMENT: Be sure to enclose the correct filing fee with your filing. If paying by credit card, be sure to include the e-Payment Authorization form with your filing. Your filing will be rejected if the payment is not included or if the e-Payment Authorization form is not included if paying by credit card. Standard filing fees apply.STANDARD PROCESSING requests may be submitted by: - E-mail to CorpFilings@wvsos.gov - Fax - Walk in delivery (drop off service only filed within 5-10 business days) READ CAREFULLY BEFORE SUBMITTING - Expedite service is NOT AVAILABLE for the following filings: West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov Customer Order RequestSUBMIT THIS COMPLETED FORM WITH YOUR FILING. Order Processing Requested*: * * * Expedite Processing Requires Additional Fees * * * Standard Processing** 24-HOUR Expedite*** 2-HOUR Expedite 1-HOUR Expedite Name of Entity: Return filing to: (Return Address) Contact Name: Phone: Return Delivery Options: Email or Fax options do not receive a copy via mail; must be ordered separately. Email to: Fax to: Hold for Pick Up UPS: Acct # Other (explain below): (additional $500.00 fee included)(additional $25.00 fee included)(additional $250.00 fee included) FedEx: Acct # Mail to Return Address above Order Description (include items being ordered and fee breakdown): *PLEASE NOTE: Original paperwork is kept by this office. Include a copy of the original filing ifyou want a file stamped copy returned to you at no extra charge. Certified copy requests are an additional $15 per certified copy being requested. Total Amount: Payment Method: Cash (Do Not mail cash) Pre-paid Acct #: Credit Card (Must attach e-Payment Authorization request form including payment information.) Check/Money Order *"Processing" indicates the filing will be completed and registered in the Secretary of State registration database. **Standard Processing applications received by E-MAIL or FAX must include the e-Payment Authorization form with credit card information. ***NOTE: Orders filed in person through any Secretary of State office location requesting the filing be processed will be assessed a 24-HOUR Expedite fee of $25.00 per order.(Avg. processing turnaround 5-10 business days)Rev. 6/2018Attach signed pre-paid slip. >> Tax Department filings including Sole Proprietorships, General Partnerships, and Associations >> Dissolution or Withdrawal of Corporation, Voluntary Association or Business Trust Email to: CorpFilings@wvsos.govEmail to: eFilings@wvsos.gov 24-hour, 2-hour and 1-hour Expedite Service GuidelinesMAC WARNER Secretary of State State Capitol Building Charleston, WV 25305 Phone: (304) 558-6000 Website: www.sos.wv.gov IMPORTANT: To ensure expedited service, please mark 223EXPEDITE224 in a conspicuous place at the top of the service request. Please indicate method of delivery. 24-HOUR EXPEDITE SERVICE The Secretary of State offers a 24-hour expedite service on most business organization filings processed by this office. If you choose to utilize this service, please enclose with your filing the additional expedite fee. Please note that this expedite fee is in addition to the standard fee charged on each filing and/or order. You must mark the document with your 22324-HOUR EXPEDITE224 request. If using a cover letter, note that you are requesting 24-hour expedited service, and include your telephone number and return inform