Dba / Assumed Name Form - Premier Corporate Services
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1DBA / Assumed Name Form
Today’s Date__________________________
Contact/Email__________________________
______________________________________________________________
Firm/Name
__________________________
___________________________
Phone #
Your Fax #
Address for delivery of Documents __________________________________________________________________
__________________________________________________________________________________________
1. Level of Service:
Routine ____________
Expedited ____________
* Fee / Timeframe will vary by State
_________________________________________
2.
State of Assumed Name / DBA Request
_____________________________________________________
3. DBA Name Choice
_____________________________________________________
4. Current Entity Name
_______________________________________________________
5. Business Purpose
6. If this is a foreign entity: The Domestic State is _____________________ Date Filed: _______________
__________________________________________________
7. Principle Business Address for DBA
____________________________________________
__________________
County
Director / Member / Manager / Officer Information ( You must have a minimum of one, who authorizes this DBA )
____________________________
__________________
8. Name
Title
560 Hudson St., Suite 3-4, Hackensack, NJ 07601
Phone: 718-317-9727 / Fax: 718-306-9258
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