Registration Of Fictitious Name - Missouri Secretary Of State

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State of Missouri

Matt Blunt, Secretary of State

Corporations Division

P.O. Box 778 / 600 W. Main Street, Rm 322

Jefferson City, MO 65102

Registration of Fictitious Name

(Submit in duplicate with filing fee of $7)

)

(Must be typed or printed

This information is for the use of the public and gives no protection to the name being registered. There is no provision in this

Chapter to keep another person or business entity from adopting and using the same name. (Chapter 417, RSMo)

The undersigned is doing business under the following name, and at the following address:

Business name to be registered:

________________________________________________________________________

Business Address:

________________________________________________________________________

(P.O. Box alone not acceptable)

City, State and Zip Code:

________________________________________________________________________

The parties having an interest in the business, and the percentage they own are (if a business entity is owner, indicate business name

and percentage owned. If all parties are jointly and severally liable, percentage of ownership need not be listed):

If listed,

Percentage

Name of Owners,

of ownership

Individual or

must equal

Business Entity

Street and Number

City and State

Zip Code

100%

____________________________________________________________________________________________________________

In Affirmation thereof, the facts stated above are true:

(The undersigned understands that false statements made in this filing are subject to the penalties of a false declaration under Section 575.060 RSMo 1986.)

____________________________________________________________________________________________________________

(Authorized Signature)

(Printed Name)

(Date)

____________________________________________________________________________________________________________

(Authorized Signature)

(Printed Name)

(Date)

____________________________________________________________________________________________________________

(Authorized Signature)

(Printed Name)

(Date)