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Publish Fictitious Name

* = Required Fields

    County - Newspaper (Please choose one)*

Filing Number*   Filing Date(mm/dd/yr)* (Usually ink-stamped on the upper-right corner)

          Fictitious Business Name*   2nd Name (Optional)               

     			Located At Address* 
                                      City* 
        	       		     State* 
				  Zip Code* 
               			      Phone (Optional)
                                        Fax (Optional)
				      Email (Optional-required for email receipt)
               			Web Address (Optional)
                                     
               	  	    Mailing Address (Optional)
                               Mailing City (Optional)
                   	      Mailing State (Optional)
 			   Mailing Zip Code (Optional)

 This business is Conducted by* An Individual    Joint Venture A Limited Liability Company

                                                      Husband and Wife A Corporation An Unincorporated Associateion-Other than a Partnership

                                                      A General Partnership    A Business Trust    Other (Please Specify Below)

                                                      A Limited Partnership    Co-Partners    

 The First Day of Business Was* (mm/dd/yr) - If business has not started, write "NONE" in the box.

 The business is Hereby Registered by the following*

              1st Owner/Officer First Name* 
               1st Owner/Officer Last Name*  
                                     Title* 
Residence Address or STATE if incorporated* 
                                      City* 
        	       		     State* 
				  Zip Code* 
               2nd Owner/Officer First Name (Optional)
                2nd Owner/Officer Last Name (Optional) 
                                      Title (Optional)
 Residence Address or STATE if incorporated (Optional)
                                       City (Optional)
                   		      State (Optional)
 				   Zip Code (Optional)
                   		  
               3rd Owner/Officer First Name (Optional)
                3rd Owner/Officer Last Name (Optional)
                                      Title (Optional)
 Residence Address or STATE if incorporated (Optional)
                                       City (Optional)
                   		      State (Optional)
 				   Zip Code (Optional)
                   		    
               4th Owner/Officer First Name (Optional)
                4th Owner/Officer Last Name (Optional)
                                      Title (Optional)
 Residence Address or STATE if incorporated (Optional)
                                       City (Optional)
                   		      State (Optional)
 				   Zip Code (Optional)

Best description of your business:

Your primary customers are:

Fees: $14.95 for one owner/officer and one fictitious business name.  $1.00 will be added for EACH additional owner/officer or fictitious business name. 

I authorize BENTHAM & ASSOCIATES, billing agent for Newbusinesses.com, to charge the applicable fee described above.  I acknowledge the information provided above is accurate and will be used to publish required listing in the newspaper.  Furthermore, I understand there is no refund after this form has been submitted and publishing may take up to 10 days after charge is authorized.

Please email me free offerings, updates, news, and information monthly.

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Revised: 09/13/04

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