Form Asn - Certificate Of Assumed Name (Domestic Or Foreign Business Entity)
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1
2C
K
OMMONWEALTH OF
ENTUCKY
E
N. W
, S
S
LAINE
ALKER
ECRETARY OF
TATE
_________________________________________________________________________________________________________________________
Division of Business Filings
Certificate of Assumed Name
ASN
Business Filings
(Domestic or Foreign Business Entity)
PO Box 718
Frankfort, KY 40602
(502) 564-3490
__________________________________________________________________________________________
Pursuant to the provisions of KRS 365, the undersigned applies to assume a name and, for that purpose, submits the
following statement:
1. The assumed name is: ___________________________________________________________________________.
2. The name of the business entity (and in the case of general partnership, the partners) that is/are adopting the assumed
name:
_________________________________________________________________________________________________
Name must be identical to the name on record with the Secretary of State.)
3. The “real name” is
(you must check one):
_____a Domestic General Partnership
_____a Foreign General Partnership
_____a Domestic Limited Liability Partnership
_____a Foreign Limited Liability Partnership
_____a Domestic Limited Partnership
_____a Foreign Limited Partnership
_____a Domestic Business Trust
_____a Foreign Business Trust
_____a Domestic Corporation
_____a Foreign Corporation
_____a Domestic Limited Liability Company
_____a Foreign Limited Liability Company
4. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date
or the delayed effective cannot be prior to the date the application is filed. The date and/or time is__________________.
(Delayed effective date
and/or time)
5. The business is organized and existing in the state or country of __________________________________________.
6. The mailing address is:
____________________________________________ ___________________ _____________ ___________________.
Street Address or Post Office Box Numbers
City
State
Zip
I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct.
_______________________________ __________________________ ___________________ ___________________
Authorized Party Signature
Printed Name
Title
Date
(04/11)
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