Business DBA Registration Form

Business DBA Registration Form

This Business DBA Registration Form (the "Registration" or "Agreement") documents the application to register a fictitious business name and the agreement between the applying entity and the registering authority or agent concerning the use of the registered name and related administrative obligations.

Recitals

WHEREAS, Applicant Name: (the "Applicant") seeks to conduct business under a fictitious business name; and

WHEREAS, Applicant desires that the fictitious business name be registered and acknowledged for public notice and for the purpose of transacting business in the jurisdiction identified below; and

WHEREAS, Registrar Representative: will accept and process the registration in accordance with the administrative and fee terms set forth herein.

Business Information

Sole Proprietorship Partnership Corporation Limited Liability Company (LLC) Other

Owners / Persons with Authority

Scope of Use

Describe the primary goods, services, marketing or activities to be conducted under the registered fictitious name:

Fees and Payment Terms

Registration Fee Amount: $

Late Payment: A late fee of will accrue on outstanding amounts commencing five (5) days after the payment due date. Applicant shall also be responsible for reasonable collection costs and legal fees incurred to collect past-due amounts.

Term and Termination

Registration Effective Date:    Registration Expiration Date (if applicable):

Either party may terminate this Registration for cause upon written notice served to the other party. Termination for convenience by Applicant requires prior written notice of days.

Confidentiality

Applicant and Registrar each agree that any non-public proprietary information exchanged in connection with this Registration, including but not limited to pricing, financial data, trade secrets and other confidential business information, shall be maintained in confidence and disclosed only to those officers, employees or advisors with a need to know. Confidential information does not include information that becomes generally available to the public other than by a breach of this clause, or information independently developed by a party without use of the other party’s confidential information.

Acknowledgement of Confidentiality Obligations: I acknowledge and accept the confidentiality provisions above.

Governing Law; Compliance

This Registration and any dispute arising from or related to it shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles. Applicant represents that the information provided herein is true and that Applicant will comply with all applicable local, state and federal laws in the use of the fictitious business name.

Entire Agreement

This Registration constitutes the entire agreement between the parties with respect to the registration and use of the fictitious business name and supersedes all prior proposals, negotiations and agreements, whether written or oral. Any amendment or modification must be in writing and signed by both parties.

Applicant Certification

I certify, under penalty of perjury, that the information provided in this Registration is true and accurate to the best of my knowledge, that I am authorized to file this registration on behalf of the Applicant, and that I will notify the Registrar promptly of any material changes to the information provided.

Applicant Certification: I certify the foregoing.

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