Form Cr101 - Assumed Business Name - New Registration
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1Phone: (503) 986-2200
Assumed Business Name—New Registration
Fax: (503) 378-4381
For office use only
Secretary of State
Corporation Division
255 Capitol St. NE, Suite 151
Salem, OR 97310-1327
Registry Number: ________________________________
Reset Form
Attach Additional Sheet if Necessary
Please Type or Print Legibly in Black Ink
1) A
B
N
_________________________________________________________________________________
SSUMED
USINESS
AME
2) D
B
4) A
R
ESCRIPTION OF
USINESS
UTHORIZED
EPRESENTATIVE (One name only)
CHECK HERE TO INDICATE ON YOUR REGISTRATION THAT YOU
5) M
A
A
R
AILING
DDRESS FOR
UTHORIZED
EP (Address, city, state, zip)
DO NOT WANT MAIL SOLICITATION.
PLEASE NOTE, THERE IS NO
OBLIGATION ON THE PART OF PERSONS USING OUR LISTS TO REFRAIN FROM
MAILING SOLICITATIONS. THE MARK IS SIMPLY INFORMATIONAL. ORS 56.022
3) P
P
B
RINCIPAL
LACE OF
USINESS (Street address, city, state, zip)
6) R
EGISTRANTS (List names and street addresses of registrants. Attach a separate sheet if necessary.)
Name
Street Address
City/State/Zip
7) C
Baker
Crook
Harney
Lake
Morrow
Union
OUNTIES
Benton
Curry
Hood River
Lane
Multnomah
Wallowa
Clackamas
Deschutes
Jackson
Lincoln
Polk
Wasco
All Counties
(Statewide)
Clatsop
Douglas
Jefferson
Linn
Sherman
Washington
Columbia
Gilliam
Josephine
Malheur
Tillamook
Wheeler
Coos
Grant
Klamath
Marion
Umatilla
Yamhill
8) E
XECUTION (All registrants must sign.)
FEES
Required Filing Fee
$
10
$2 for each county
$ _____
Confirmation copy
$
5
(optional)
TOTAL (nonrefundable)
$ _____
Please make check payable to
“Corporation Division.”
NOTE: Filing fees may be paid
with VISA or MasterCard. The
card number and expiration date
should be submitted on a separate
9) C
N
D
P
N
- I
A
C
ONTACT
AME
AYTIME
HONE
UMBER
NCLUDING
REA
ODE
sheet for your protection.
CR101 (Rev. 10/2000)
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