Fictitious Name Registration Form - 2005 Page 2
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1
2State of Missouri
This form is designed to be filled out online for your
convenience. Enter the data and press print when
Robin Carnahan, Secretary of State
ready. Use the reset button to reset the entire form.
Corporations Division
P.O. Box 778 / 600 W. Main Street, Rm 322
Print
Reset
Jefferson City, MO 65102
Registration of Fictitious Name
(Submit with filing fee of $7)
(Must be typed or printed)
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)
The undersigned is doing business under the following name, and at the following address:
Business name to be registered:
____________________________________________________________________________
Business Address:
____________________________________________________________________________
(P.O. Box may only be used in addition to a physical street address)
City, State and Zip Code:
____________________________________________________________________________
The parties having an interest in the business, and the percentage they own are (If a business entity is owner, indicate business name and
percentage owned. If all parties are jointly and severally liable, percentage of ownership need not be listed.):
If listed,
Percentage of
ownership
Name of Owners,
must equal
Individual or
Street and Number
Business Entity
City and State
Zip Code
100%
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
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 provided under Section 575.060 RSMo)
________________________________________________________________________________________________________________
Authorized Signature
Printed Name
Date
________________________________________________________________________________________________________________
Authorized Signature
Printed Name
Date
________________________________________________________________________________________________________________
Authorized Signature
Printed Name
Date
Name and address to return filed document:
Name: __________________________________________
Address: _________________________________________
City, State, and Zip Code: __________________________
Corp. 56 (01/05)
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