Pre-Need Establishment Registration Form - Mississippi Secretary Of State

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MISSISSIPPI SECRETARY OF STATE
PRE-NEED ESTABLISHMENT
REGISTRATION FORM
Eric Clark, Secretary of State
MS Registration M - __________
Initial registration
Annual Report
Amendments
(Changes in this information are required to be provided to the Secretary of State's Office within 30 days of
when the change occurs.)
PLEASE TYPE OR PRINT IN BLACK INK.
1. Organization's Legal Name ________________________________________________________________
2. a. Any other name(s) used _________________________________________________________________
__________________________________________________________________________________________
b. Please list all branch offices, addresses and telephone numbers:
(Attach separate sheet if necessary.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Mailing address __________________________________________________________________________
City ___________________________________________ State _____________ Zip Code ______________
4. Physical Address (if different) ______________________________________________________________
City __________________________________________ State _____________ Zip Code _______________
5. Contact person __________________________________________________________________________
6. Telephone number (s)
7. Fax number (s) __________________________
8. E-mail address___________________________________________________________________________
9. Website address (if applicable)______________________________________________________________
10. Fiscal year end (day/month) ________________________________________________________________
Rev. 05/2004

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