APPLICATION FOR REGISTRATION OF FICTITIOUS NAME
Note: Acknowledgements/certificates will be sent to the address in Section 1 only.
1.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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)
FEI Number: ________________________________
This space for office use only
A. Owner(s) of Fictitious Name If Individual(s): (Use an attachment if necessary):
1.
______________________________________
2.
______________________________________
Last
First
M.I.
Last
First
M.I.
______________________________________
______________________________________
Address
Address
______________________________________
______________________________________
City
State
Zip Code
City
State
Zip Code
B. Owner(s) of Fictitious Name If other than an individual: (Use attachment if necessary):
1.
______________________________________
2.
______________________________________
Entity Name
Entity Name
______________________________________
______________________________________
Address
Address
______________________________________
______________________________________
City
State
Zip Code
City
State
Zip Code
Florida Document Number ______________
Florida Document Number _______________
FEI Number: __________________________
FEI Number: __________________________
Applied for
Not Applicable
Applied for
Not Applicable
I the undersigned, being an owner 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 further certify that the fictitious name to be registered has been advertised at least once in a newspaper as defined in chapter
50, Florida Statutes, in the county where the principal place of business is located. I understand that the signature below shall have the same legal
effect as if made under oath and I am aware that false information submitted in a document to the Department of State constitutes a third degree
f
elony as provided for in s.817.155, F.S.
__________________________________________
__________________________________________
Signature of Owner in Section 1
Date
E-mail address: (to be used for future renewal notification)
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
registration number ______________________
__________________________________________
__________________________________________
Signature of Owner of Registration being Cancelled
Date
Signature of Owner of Registration being Cancelled
Date
Mark the applicable boxes
Certificate of Status — $10
Certified Copy — $30
NON-REFUNDABLE PROCESSING FEE: $50
CR4E001 (8/15)