Fictitious Business Name Statement - 2014 (Page 3 of 3) in pdf

Fictitious Business Name Statement - 2014 Page 3

TO BE COMPLETED BY AUTHORIZED AGENT

In accordance with Section 17913 of the California Business and Professions Code, the following identifying information is

required to file a Fictitious Business Name Statement.

The Agent must present ID and sign in the presence of a Deputy County Clerk

Agent Name

First Name

Last Name

Fictitious Business Name:

, certify under penalty of perjury under the laws of the State of California that I am the

(Print Name)

authorized agent filing this Fictitious Business Name on behalf of the registrant.

Signed on this date:

, 20___

(Authorized Agent Signature)

To be completed by Deputy County Clerk

Agent ID #___________________Exp. Date_________ Deputy Signature_________________________

To be completed by the Registrant

, certify under penalty of perjury under the laws of the State of California that I am

(Print Name)

the registrant filing this Fictitious Business Name Statement and am authorized to submit said statement to the County

Clerk’s Office for filing. I understand that if I willfully make a false statement on this affidavit, I may be punished by a fine

not to exceed one thousand dollars ($1,000).

I also declare that I am authorizing the agent listed above to submit this Fictitious Business Name Statement on

my behalf.

Signed on this date

, 20___

(Registrant Signature)

01-2015

Fictitious Business Name Statement - 2014 Page 3