Certificate Of Doing Business Under An Assumed Name
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1Certificate of Doing Business Under an Assumed Name (D/B/A)
Broome County Clerk’s Office
Broome County Office Building, 3
Floor, 44 Hawley Street, Binghamton, NY 13902
rd
RICHARD R. BLYTHE, County Clerk (607) 778-2451
I HEREBY CERTIFY that I am conducting or transacting business in Broome
County pursuant to Section 130 of the New York State General Business Law, under the
name or designation and at the address of:
Business Name:_____________________________________________________________________
Business Address:___________________________________________________________________
_____________________________________________________________________________________
Phone Number: ______________________________________________________________________
My full name and place of residence is:
Name:_______________________________________________________________________________
Address: _____________________________________________________________________________
______________________________________________________________________________________
Phone Number: _______________________________________________________________________
I FURTHER CERTIFY that I am successor in interest to ________________________________________
(Name of former owner of business, if applicable)
who formerly used this name or names to conduct or transact business.
I FURTHER CERTIFY that I am _____ years of age (if under 18).
My Signature:___________________________________________________ Date: _______________________________
STATE OF NEW YORK
}
ss:
COUNTY OF BROOME
On this ________________ day of ______________________, year _____________ before me, the undersigned,
personally appeared ___________________________________________________, personally known to me or
proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the
within instrument and acknowledged to me that he/she executed the same in his/her capacity and that by
his/her signature on the instrument, the individual, or the person upon behalf of which the individual
acted, executed the instrument.
________________________________________________________________
Signature and Office of Individual taking acknowledgement (Notary Public)
Instructions: use this form for DBA by INDIVIDUAL(S): Complete the form BUT DO NOT SIGN IT until in the presence
of a Notary Public or deputy County Clerk. There are Notary Publics on staff who will witness your signature.
Bring
the form with you to the Broome County Clerk’s Office, 3
Floor, County Office Building together with $25 cash (or
rd
check made payable to Broome County Clerk). Certified copies are $5.20 per copy. Our document filing hours are
9:00 am to 4:45 pm Monday through Friday except holidays. If you have any questions please call (607) 778-2451.
Legal questions should always be addressed by an attorney.
Revised 2/2009
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Parent category: Business