Form 102 - Assumed Business Name-Amendment

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Phone: (503) 986-2200
Assumed Business Name – Amendment
Fax: (503) 378-4381
Print
Secretary of State
Corporation Division
Reset
255 Capitol St. NE, Suite 151
Salem, OR 97310-1327
Save As
R
N
:
EGISTRY
UMBER
In accordance with Oregon Revised Statute 192.410-192.490, the information on this application is public record.
We must release this information to all parties upon request and it will be posted on our website.
For office use only
Please Type or Print Legibly in Black Ink. Attach Additional Sheet if Necessary.
To change business name use new registration, Form 101.
1)
A
B
N
:
SSUMED
USINESS
AME
2)
D
B
4)
N
A
R
ESCRIPTION OF
USINESS
AME OF
UTHORIZED
EPRESENTATIVE (One name only)
C
N
ONTINUING
EW
3)
P
P
B
RINCIPAL
LACE OF
USINESS (Street address, city, state, zip)
M
A
A
R
5)
AILING
DDRESS OF
UTHORIZED
EPRESENTATIVE
6)
R
EGISTRANTS (List name and street address of each person or entity who will conduct or transact business under the assumed business name.)
(All new registrants must be listed. If registrants are withdrawing, both continuing and withdrawing registrants must be listed.)
N
R
C
R
W
R
EW
EGISTRANTS
(Name, Street Address)
ONTINUING
EGISTRANTS
(Name, Street Address)
ITHDRAWING
EGISTRANTS
7)
C
OUNTIES
Baker
Crook
Harney
Lake
Morrow
Union
A
C
Benton
Curry
Hood River
Lane
Multnomah
Wallowa
LL
OUNTIES
(Statewide)
Clackamas
Deschutes
Jackson
Lincoln
Polk
Wasco
Clatsop
Douglas
Jefferson
Linn
Sherman
Washington
Columbia
Gilliam
Josephine
Malheur
Tillamook
Wheeler
Coos
Grant
Klamath
Marion
Umatilla
Yamhill
8)
S
IGNATURES Any change requires a signature. New registrants must sign. If any registrants are WITHDRAWING, withdrawing Registrants or Authorized
Representative must sign. If there is a change of Authorized Representative, all registrants must sign.
FEES
9)
C
N
D
P
N
ONTACT
AME (To resolve questions with this filing.)
AYTIME
HONE
UMBER (Include area code.)
No Processing Fee
Confirmation Copy (Optional) $5.
102 (Rev. 8/05)

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