Fill and Sign the Form 503general Information Assumed Name Certificate

ASSUMED NAME CERTIFICATE 1. The name of the (individual, corporation, limited liability company, limited partnership, or registered limited liability partnership as stated in its articles of incorpora tion, articles of organization, certificate of limited partnership, application, or comparable document ) is _______. 2. The assumed name under which the business or professional service is or is to be conducted or rendered is “_____.” 3. The state, country, or other jurisdiction under the laws of which it (was incorporated, organized, associated, or will do business) is _____, and the address of its registered or similar office in the jurisdiction is _____. 4. The period, not to exceed 10 years, during which the assumed name will be issued is _____ years. 5. The entity is a (circle one): corporation, non-profit corporation, professional corporation, professional association, limited liability company, limited partnership, registered l imited liability partnership or some other type of incorporated business, professional or other association (specify) _____. 6. If the entity is required to maintain a registered office in ( name of sta te ), the address of the registered office is _____, and the name of its registered agent at such address is _____. The address of the principal office (if not the same as the registered office) is _____. 7. If the entity is not required to or does not maintain a registered office in ( na me of state ) is _____ and if the entity is not incorporated, organized, or associated under the laws of the State of _____, the address of its place of business in ( name of state ) is _____. 8. The county or counties where business or professional services are being or are to be conducted or rendered under such assumed name are (if applicable, use the designation “ALL” or “ALL EXCEPT”): Name: Title: (Acknowledgment)