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					INSTRUCTIONS AND INFORMATION FOR BUSINESS NAME CHANGE APPLICATION Application begins on page 3 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at (850) 487-1395. Applicants are cautioned to read questions thoroughly. Be certain that all questions are answered truthfully and that all requested information is furnished. IMPORTANT NOTE: This application applies only when the name of your corporation, partnership or business operating under a fictitious name has amended its name. A copy of the Articles of Amendment from the Secretary of State’s Office or other pertinent documents which reflect the name change must be submitted with this application.

FEES DEFINED: Business Name Change Application Application Fee $25

Architecture Business or Interior Design Business Name Change
2007 July 1 of 5

APPLICATION CHECKLIST: TRANSACTION APPLICATION REQUIREMENTS Pay $25 fee (make check payable to the Department of Business and Professional Regulation) Complete DBPR 0020-1 – Master Organization Application Complete DBPR 4005 – Business Name Change Application Submit copy of the Articles of Amendment from the Secretary of State’s Office or other pertinent documents which reflect the name change. Submit copies of current Department of Business and Professional Regulation licenses issued to each registrant employed by the applicant firm who practices in Florida. Submit certificate of Status from the Florida Secretary of State’s Office for corporate entities which indicates the company is in good standing. A certificate which identifies the date a company was first authorized to transact business in Florida is required for newly formed businesses. The certificate should be accompanied by Articles of Incorporation. Corporate entities must provide a copy of the Articles of Incorporation as filed with the Secretary of State located in the firm’s base state. The articles must identify a licensed professional as a principal officer of the firm. If the licensee who qualifies the firm is not identified as a principal officer in the original article one of the following must be provided: 1. Amended Articles of Incorporation which clearly designates such professional as a principal officer of the firm. Amended articles must also reflect the date they were filed with the Secretary of State’s Office. 2. A copy of the most recent annual report which reflects the election of the principal qualifier for the firm. The report must also reflect the date filed with the Secretary of State’s Office. Copy of proposed business stationery which: 1. Clearly identifies where the firm’s registration number will appear once it has been issued. 2. Clearly denotes the professional service which will be offered through said company, i.e. architecture, interior design.

Name Change

Please send your completed application, documentation and required fee(s) to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0783

www.myflorida.com/

Architecture Business or Interior Design Business Name Change
2007 July 2 of 5

DBPR AID-4005 Business Name Change Application STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 1940 North Monroe Street Tallahassee, FL 32399-0783 NOTE – This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at (850) 487-1395. CHECK TRANSACTION REQUESTED Transaction Type: Architecture Business Name Change Interior Design Business Name Change LICENSEE INFORMATION License Number New Business Name Business Name as Currently Licensed Address of Principal Place of Business City State Zip Telephone # of Principal Place of Business

BRANCH OFFICES If this company maintains its headquarters outside the State of Florida, a Florida resident agent must be identified:______________________________________________________________________________ ______ Type of Office Marketing Office Full Service Marketing Office Full Service Marketing Office Full Service Marketing Office Full Service Marketing Office Full Service Marketing Office Full Service If branch office is a full service office, list the name and license number of the licensed professional with responsible supervisory control: Name License # Address Telephone #

Architecture Business or Interior Design Business Name Change
2007 July 3 of 5

Identify the names and registration numbers of the professionals who qualify the firm for architecture or interior design services in the State of Florida Name License # Signature

Provide the name and license numbers for all other architects and interior designers employed by the company Name License #

NAME CHANGE INFORMATION Date company’s name change took effect: __________________. If over two months since change took effect, list last three projects initiated or completed by the company under new name: Client Name/Address Project Location (city/state) Completion Date

ATTEST STATEMENT I have read the questions in this application and have answered them completely and truthfully to the best of my knowledge. I have successfully completed the education, if any, required for the level of licensure, registration, or certification sought. I have the amount of experience required, if any, for the level of licensure, registration, or certification sought. I pledge to comply with the applicable standards of practice upon licensure, registration, or certification. I understand the types of misconduct for which disciplinary proceedings may be initiated. Giving knowingly misleading statements or knowing misrepresentation when applying for a license constitutes a felony of the third degree and may result in licensure denial or revocation. Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true. Signature: Print Name: Social Security Number:
Architecture Business or Interior Design Business Name Change
2007 July 4 of 5

DBPR 0020-1 – Master Organization Application STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION

ORGANIZATION INFORMATION Federal Employer ID Number/Social Security Number* Organization/Applicant Name Doing Business As (D/B/A) Name Ownership: Proprietorship Corporation Partnership Joint Venture Agreement Trust Agreement Estate Professional Association Other MAILING ADDRESS Street Address or P.O. Box

City County (if Florida address) Contact Name Primary Phone Number Street Address Primary E-Mail Address Country

State

Zip Code (+4 optional)

CONTACT INFORMATION

RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)

City County (if Florida address) Street Address Country

State

Zip Code (+4 optional)

BUSINESS LOCATION ADDRESS

City County (if Florida address) Country

State

Zip Code (+4 optional)

ADDITIONAL CONTACT INFORMATION (OPTIONAL) Alternate Phone Number Fax Number Alternate E-Mail Address
*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.

Architecture Business or Interior Design Business Name Change
2007 July 5 of 5