CONDUCT OF BUSINESS UNDER FICTITIOUS OR ASSUMED NAMED

Date:

To:

State of:

            Pursuant to                                                       , relating to the conduct of business

under                                        name, the undersigned, hereby present(s) for filing the

following application in the office of:

1.  The                                     name under which the business is, or will be,    carried on is:

2.  The real name and address of each person owning or interested in the

       business is:

3.  The nature of the business is:

4.  The business will be conducted at:

STATE OF

COUNTY OF

On                                           before me,                                                       ,

personally appeared                                                                                              ,

personally known to me (or proved to me on the basis of satisfactory evidence) to be

the person(s) whose name(s) is/are/subscribed to the within instrument and

acknowledged to me that he/she/they executed the same in his/her/their authorized

capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),

or the entity upon behalf of which the person(s) acted, executed the

instrument.WITNESS my hand and official seal.

Signature

                                                                        Affiant              Known             Unknown

                                                                        ID Produced

                                                                                                                        (Seal)