Application For Registration Of Fictitious Name printable pdf download

APPLICATION FOR REGISTRATION OF FICTITIOUS NAME

Note: Acknowledgements /certificates will be sent to the address in Section 1 only.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Fictitious Name to be Registered (see instructions if name includes “Corp” or “Inc”)

____________________________________________________________

Mailing Address of Business

____________________________________________________________

City

State

Zip Code

3. Florida County of principal place of business: ______________

____________________________________________________________

(see instructions if more than one county)

4. FEI Number: ____________________________

This space for office use only

A. Owner(s) of Fictitious Name If Individual(s): (Use an attachment if necessary):

______________________________________

Last

First

M.I.

Last

First

M.I.

______________________________________

Address

______________________________________

City

State

Zip Code

City

State

Zip Code

B. Owner(s) of Fictitious Name If other than an individual: (Use attachment if necessary):

______________________________________

Entity Name

______________________________________

Address

______________________________________

City

State

Zip Code

City

State

Zip Code

Florida Registration Number ______________

FEI Number: __________________________

Applied for

Not Applicable

Applied for

Not Applicable

I (we) the undersigned, being the sole (all the) party(ies) owning interest in the above fictitious name, certify that the information indicated on this form

is true and accurate. In accordance with Section 865.09, F.S., I (we) understand that the signature(s) below shall have the same legal effect as if

made under oath. (At Least One Signature Required)

__________________________________________

Signature of Owner

Date

Signature of Owner

Date

Phone Number: ____________________________

FOR CANCELLATION COMPLETE SECTION 4 ONLY:

FOR FICTITIOUS NAME OR OWNERSHIP CHANGE COMPLETE SECTIONS 1 THROUGH 4:

I (we) the undersigned, hereby cancel the fictitious name ______________________________

______________________, which was registered on ________________ and was assigned