Trade Name Or Assumed Business Name Filing Form

Trade Name Or Assumed Business Name Filing Form - 2003

TRADE NAME OR ASSUMED BUSINESS NAME FILING

Oregon Department of Consumer & Business Services

Division of Finance & Corporate Securities

350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881

Mailing address: P.O. Box 14480, Salem, OR 97309-0405

(503) 378-4140 Fax: (503) 947-7862 TTY: (503) 378-4100

Pursuant to ORS 59.175(7) and OAR 441-175-0171

Date:

Applicant’s CRD number:

Trade name or

assumed business name:

Applicant’s name:

Business address:

City, State, ZIP:

Contact’s name:

(

)

(

)

Phone number:

Fax:

Signature:

Print name:

Title

(if applicable):

Filing fee: $50

Visa

MasterCard

Make check or money order payable to Department

Credit card number

Expiration date

of Consumer & Business Services. If paying by credit

card, applicant must sign credit-card information box.

Name of cardholder as shown on credit card

Mail application with payment to:

DCBS — Fiscal Services

Cardholder signature

Amount

P.O. Box 14610

Salem, OR 97309-0405

Fiscal use only: 62110/1002 $50.00

440-2774 (4/03/COM/WEB)

Trade Name Or Assumed Business Name Filing Form - 2003