Fill and Sign the Arkansas Secretary of State Business Ampamp Commercial Services Form

APPLICA TION FOR FICTITIOUS NAME Select entity type: [ ] For-Profit Corporation ($25.00 fee) [ ] Nonprofit Corporation ($25.00 fee) [ ] General Partnership ($15.00 fee) [ ] Limited Partnership ($15.00 fee) [ ] LLC ($25.00 fee) [ ] LLP ($15.00 fee) [ ] LLLP ($15.00 fee) Pursuant to the provisions of Arkansas law , the undersigned entity hereby applies for the use of a fictitious name and submits herewith the following statement: 1. The fictitious name under which the business is being, or will be, conducted by this entity is: ___________________________________________________________________________ 2. The character of the business being, or to be, conducted under such fictitious name is: ___________________________________________________________________________ 3. a) The entity name of the applicant and its date of qualification in Arkansas: ____________________ ___________________________________________________________________________ b) The entity is [ ] domestic [ ] foreign (state of domestic registration) ________________ c) The location (city and street address) of the registered of fice of the applicant entity in Arkansas is: __________________________________________________________________________ Street City State ZIP Code I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or impris - onment up to 30 days. Authorizing Of ficer _________________________________________________________________ (T ype or Print) Authorized Signature: ______________________________________________________________ (Chairman, Partner or other authorized person) Address: _________________________________________________________________________ Fee: see top of page. Make payable to Arkansas Secretary of State. DN-18/F-18/Rev . 4/06 INSTRUCTIONS: File with the Secretary of State's Of fice, Business Services Division, State Capitol, Little Rock, Arkansas 72201-1094. A copy will be returned to the entity and must be filed with the County Clerk in the coun - ty in which the entity’s registered of fice is located (unless registered of fice is in Pulaski County). A r k a n s a s S e c r e t a r y o f S t a t e State Capitol • Little R ock, Arkansas 7220 1- 1 094 50 1-682-3409 • www .sos.arkansas.go v Business & Commer cial Services, 250 Victor y Building, 1 40 1 W . Capitol, Little Rock Charlie Daniels