Free corp 56 - Missouri

State of Missouri
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This form is designed to be filled out online for your convenience. Please read the instructions carefully. Complete the necessary information, print, sign and mail.
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Robin Carnahan, Secretary of State
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This information is for the use of the public and gives no protection to the name being registered. There is no provision in this Chapter to keep another person or business entity from adopting and using the same name. The fictitious name registration expires 5 years from the filing date. (Chapter 417, RSMo) Please check all that apply: New Registration Renewal _______________ X
Registration #

The undersigned is doing business under the following name and at the following address: Business name to be registered: Business Address:
(PO Box may only be used in addition to a physical street address)

City, State and Zip Code: Owner Information: If a business entity is an owner, indicate business name and percentage owned. If all parties are jointly and severally liable, percentage of ownership need not be listed. Please attach a separate page for more than three owners. The parties having an interest in the business, and the percentage they own are: If Listed, Percentage of Ownership Must Equal 100%

Name of Owners, Individual or Business Entity

All owners must affirm by signing below In Affirmation thereof, the facts stated above are true and correct:
(The undersigned understands that false statements made in this filing are subject to the penalties of a false declaration under Section 575.060 RSMo)

Authorized Signature

Authorized Signature

Authorized Signature

Name and address to return filed document: Name: Address: City, State, and Zip Code:
Corp. 56 (05/2009)

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Corporations Division PO Box 2050 / 600 W. Main St., Rm. 322 Jefferson City, MO 65102

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Registration of Fictitious Name
(Submit with filing fee of $7.00) (Must be typed or printed)

Amendment X _______________
Registration #

Correction X _______________
Registration #

Charter # of Owner Required If Owned by a Business Entity

Street and Number

City and State

Zip Code

Printed Name

Date

Printed Name

Date

Printed Name

Date