Free D-05 - Arkansas

Arkansas Secre t a ry of State
Charlie Daniels
State Capitol · Little Rock, Arkansas 72201-1094 501-682-3409 · www.sos.arkansas.gov

Business & Commercial Services, 250 Victory Building, 1401 W. Capitol, Little Rock

INSTRUCTIONS: File with the Secretary of State's Business Services Division, State Capitol, Little Rock, Arkansas 72201-1094. A copy will be returned to the corporation and must be filed with the County Clerk (not required in Pulaski County) of the County in which the Corporation's registered office is located.

APPLICATION FOR REGISTRATION OF FICTITIOUS NAME
Pursuant to the provisions of Section 95 of the Arkansas Business Corporation Act (Act 576 of 1965), the undersigned corporation hereby applies for the registration of 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 corporation is:

2.

The character of the business being, or to be, conducted under such fictitious name is:

3.

a) The corporation name of the applicant:

b) The State of incorporation is:

c) The location (giving city and street address) of the registered office of the applicant corporation in Arkansas is: Street City State 4. The applicant states that if it is a foreign corporation that it is admitted to and authorized to do business in the state of Arkansas. Name of Applicant Corporation:

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 imprisonment up to 30 days.
Authorizing Officer
(Type or Print)

Authorized Signature:
President

Address: SEAL ATTEST
Secretary D-05/Rev. 4/06