CONDUCT OF BUSINESS UNDER FICTITIOUS OR ASSUMED NAMED Date: ___________________ To: ____________________________________________ State of: ___________________ Pursuant to _________________, relating to the conduct of business under ___________________ name, the undersigned, hereby present(s) for filing the following application in the office of: 1. The name under which the business is, or will be, carried on is: 2. The real name and address of each person owning or interested in the business is: 3. The nature of the business is: 4. The business will be conducted at: STATE OF ___________________ COUNTY OF _________________ On____________________before me,______________________, personally appeared ______________________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature______________________________ Affiant _____Known _____Unknown ID Produced______________________ (Seal)