Legal Fictitious Name Form

LEGAL FICTITIOUS NAME FORM

This Fictitious Name Registration Agreement (the agreement) is made and entered into as of Effective Date: by and between Registrant Name: , a business organized as with principal place of business at (hereinafter "Registrant"), and Filing Authority Name: with office address at (hereinafter "Filing Authority").

RECITALS

WHEREAS, Registrant conducts or intends to conduct business under a trade name and seeks to register and give public notice of such trade name as a fictitious name as permitted by applicable law; and

WHEREAS, Filing Authority administers the records relating to fictitious names and accepts registrations for filing in accordance with statutory processes; and

WHEREAS, the parties desire to set forth the terms of the registration and the declarations required for acceptance and public recordation;

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. FICTITIOUS NAME

Registrant hereby declares and registers the following fictitious name for use in connection with the conduct of business: Fictitious Name:

2. OWNER INFORMATION

Individual    Partnership    Corporation    Limited Liability Company (LLC)

3. BUSINESS ACTIVITY

4. TERM, EFFECTIVE DATE, AND RENEWAL

The registration shall be effective as of Effective Date: and shall remain in effect until expiration, withdrawal, or cancellation in accordance with applicable law. Registrant may apply for renewal or re-filing upon expiration.

5. REPRESENTATIONS AND WARRANTIES

Registrant represents and warrants that: (a) the information contained herein is true and correct to the best of Registrant's knowledge; (b) Registrant is authorized to transact business under the fictitious name; and (c) the use of the fictitious name will not infringe, dilute or otherwise violate the rights of any third party. Registrant covenants to promptly notify Filing Authority of any changes to the information provided.

6. USE AND RESTRICTIONS

Registrant will use the fictitious name only in a lawful manner and in accordance with applicable statutory requirements. Registrant shall not use the fictitious name to perpetrate fraud, mislead consumers, or evade legal obligations. Filing Authority's acceptance of this registration does not constitute a determination of trademark rights or exclusive use.

7. INDEMNIFICATION

Registrant agrees to indemnify, defend and hold harmless Filing Authority, its officers, agents and employees from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising out of Registrant's use of the fictitious name or any breach of the representations contained in this Agreement.

8. FEES AND PAYMENT

Payment of the required filing fee is evidence that Registrant has submitted this registration for acceptance. Acceptance and recording by Filing Authority is subject to review for compliance with filing requirements.

9. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the parties at their addresses set forth below, and shall be deemed given when received in hand or three (3) business days after deposit in the U.S. mail, postage prepaid, addressed as follows:

10. AMENDMENTS; WAIVER

This Agreement may be amended only by a written instrument signed by both parties. The failure of either party to enforce any provision shall not constitute a waiver of that provision or any other provision.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction in which the filing is recorded, without regard to principles of conflicts of law. This Agreement constitutes the entire agreement between the parties regarding the subject matter hereof and supersedes all prior understandings and agreements. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

12. CERTIFICATION

The undersigned Registrant certifies under penalty of perjury that the information provided on this form is true and correct and that the registrant is authorized to execute this registration. Registrant acknowledges that knowingly providing false statements may subject the registrant to civil and criminal penalties under applicable law.

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