Form Cr4e001 - Application For Registration Of Fictitious Name With Instructions - 2015
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1
2APPLICATION FOR REGISTRATION OF FICTITIOUS NAME
Note: Acknowledgments/certificates will be sent to the address in Section 1 only.
____________________________________________________
1.
Fictitious Name to be Registered (see instructions for certain prohibited words, abbreviations and designations)
________________________________________________________________________________________________
2.
________________________________________________________________________________________________
Mailing Address of Business
___________________________________________
____________________________
_________________
City
State
Zip
3.
Florida County of principal place of business:
_________________________________________
_______________________________________________________________________________________________
(see instructions if more than one county)
4.
FEI Number of Business:
_________________________________________________
This space for office use only
A. Registrant if individual(s): (Use an attachment if necessary):
1.
____________________ ____________________ _____ 2. ____________________ ____________________ _____
Last
First
M.I.
Last
First
M.I.
_____________________________________________________________________
_____________________________________________________________________
Address
Address
___________________________________ ___________________ _____________
___________________________________ ___________________ _____________
City
State
Zip
City
State
Zip
B. Registrant if other than an individual(s): (Use an attachment if necessary):
______________________________________________
2. ______________________________________________
Entity Name
Entity Name
_____________________________________________________________________
_____________________________________________________________________
Address
Address
___________________________________ ___________________ _____________
___________________________________ ___________________ _____________
City
State
Zip
City
State
Zip
Florida Document Number: _______________________
Florida Document Number: _______________________
FEI Number: ____________________________
FEI Number: ____________________________
○
○
○
○
Applied for
Not Applicable
Applied for
Not Applicable
I the undersigned, being a registrant for the above fictitious name, certify that the information indicated on this form is true and
accurate. In accordance with Section 865.09, F.S., I further certify that the intention to register the fictitious name to be registered
has been advertised at least once in a newspaper as defined in chapter 50, Florida Statutes, in the county in which the principal
place of business of the registrant is or will be located. I understand that the signature below shall have the same legal effect as if
made under oath and I am aware that false information submitted in a document to the Department of State constitutes a third
degree felony as provided for in s.817.155, F.S.
________________________________________________________ ________________
___________________________________________________________________________
Signature of Registrant in Section 2
Date
Email address: (to be used for future renewal notifications)
FOR
CANCELLATIONS,
COMPLETE THIS SECTION 4 ONLY:
FOR FICTITIOUS NAME REGISTRATION CHANGE, COMPLETE SECTIONS 1 THROUGH 4:
I (we) the undersigned, hereby cancel the fictitious name _________________________________________________, which was
registered on _____________________________ and assigned registration number _____________________________.
_______________________________________ ___________ _______________________________________ ___________
Signature of Registrant Whose Registration is Being Cancelled
Date
Signature of Registrant Whose Registration is Being Cancelled
Date
□
□
Mark the applicable boxes
Certificate of Status - $10
Certified Copy - $30
NON-REFUNDABLE PROCESSING FEE: $50
CR4E001 (11/17)
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