Application To Register Or Re Register Business Name {211}

Phone: (503) 986-2200 Fax: (503) 378-4381 Application to Register or Re-register Corporate Name Secretary of State Check the appropriate box below: Corporation Division THIS IS A NEW REGISTRATION 255 Capitol St. NE, Suite 151 Salem, OR 97310-1327 THIS IS A RE-REGISTRATION FilingInOregon.com REGISTRY NUMBER : In accordance with Oregon Revised Statute 192.410-192.490, the informati on on this application is public record. We must release this information to all parties upon request and it will be posted on our website.r For office use only Please Type or Print Legibly in Black Ink. Attach Additional Sheet if Necessary. 1) NAME OF CORPORATION 2) STATE OR COUNTRY OF INCORPORATION (Include an original certificate of existence, current within 60 days of delivery to the division, authenticated by the official having custody of the corporate records in the jurisdiction of incorporation.) 3) THE CORPORATION IS NOT CARRYING ON OR DOING BUSINESS IN THE STATE OF OREGON. 4) APPLICANT S NAME AND ADDRESS 5) EXECUTION Signature Printed Name Title 6) CONTACT NAME (To resolve questions with this filing.) DAYTIME PHONE NUMBER (Include area code.) FEES Required Processing Fee $0 5 Confirmation Copy (Optional) $5 Processing Fees are nonrefundable. Please make check payable to Corporation Division. NOTE: Fees may be paid with VISA or MasterCard. The card number and expiration date should be submitted on a separate sheet for your protection. 135 (Rev. 1/04)