Form Ss984 - Transmittal Information For All Business Filings (Page 2 of 2) in pdf

Form Ss984 - Transmittal Information For All Business Filings Page 2

TATE OF

OUISIANA

TOM SCHEDLER

Commercial Division

SECRETARY OF STATE

ECRETARY OF

TATE

(225) 925-4704

Fax Numbers

(225) 932-5317 Administrative Services

(225) 932-5314 Corporations

(225) 922-0452 UCC

PUBLIC OPINION POLLS CONDUCTOR

DATE OF REGISTRATION__________________________

________________________________________________________________________

(Name of person, association, partnership or corporation under which polls are conducted.)

The above named is engaged in the making of public opinion polls or samplings in the State

of Louisiana and hereby registers in accordance with Act 602 of 1972 (R.S.14:325).

CURRENT MAILING ADDRESS:

___________________________________________________

CURRENT MAILING ADDRESS OF PRINCIPAL, EXECUTIVE OFFICER (IF DIFFERENT

FROM ABOVE ADDRESS):

___________________________________________________

The $5.00 registration fee, made payable to Louisiana Secretary of State , is enclosed.

___________________________________________________

Print Name

___________________________________________________

Signature

of principal officer

___________________________________________________

Title

of principal officer

___________________________________________________________________________

Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125

Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809

SS301 Rev. 10/08

Web Site Address:

Form Ss984 - Transmittal Information For All Business Filings Page 2