Application for Registration of Fictitious Name

Fictitious Name to be Registered
FEI/EIN Number	- (Optional)
Email Address

Your acknowledgement letter, certification requests, and all future notices will be sent to this email address.

Certificate of Status	$10.00 (Optional)	What is a certificate of status?
Certified Copy	$30.00 (Optional)	What is a certified copy?

Mailing Address of Business
Mailing Address of Business	(Current)
Address Line 2
City, State	,
Zip Code
Florida County of Principal Place of Business	Multiple Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Desoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Osceola Okaloosa Okeechobee Orange Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington
Owner Name And Address

Name And Address #1 List only one individual or business entity name
Owner of Fictitious Name If An Individual: , , Last First Middle
- OR -
Owner of Fictitious Name If a Business Entity (Corporation, LLC, etc.): Entity Name Florida Document Number: (Only applies to business entity owners) FEI/EIN Number: - (Only applies to business entity owners) FEI/EIN Number Status: Applied For Not Applicable Current
Street Address
City, State	,
Zip Code & Country

 

Name And Address #2 List only one individual or business entity name
Owner of Fictitious Name If An Individual: , , Last First Middle
- OR -
Owner of Fictitious Name If a Business Entity (Corporation, LLC, etc.): Entity Name Florida Document Number: (Only applies to business entity owners) FEI/EIN Number: - (Only applies to business entity owners) FEI/EIN Number Status: Applied For Not Applicable Current
Street Address
City, State	,
Zip Code & Country

 

Name And Address #3 List only one individual or business entity name
Owner of Fictitious Name If An Individual: , , Last First Middle
- OR -
Owner of Fictitious Name If a Business Entity (Corporation, LLC, etc.): Entity Name Florida Document Number: (Only applies to business entity owners) FEI/EIN Number: - (Only applies to business entity owners) FEI/EIN Number Status: Applied For Not Applicable Current
Street Address
City, State	,
Zip Code & Country

 

Name And Address #4 List only one individual or business entity name
Owner of Fictitious Name If An Individual: , , Last First Middle
- OR -
Owner of Fictitious Name If a Business Entity (Corporation, LLC, etc.): Entity Name Florida Document Number: (Only applies to business entity owners) FEI/EIN Number: - (Only applies to business entity owners) FEI/EIN Number Status: Applied For Not Applicable Current
Street Address
City, State	,
Zip Code & Country

 

Name And Address #5 List only one individual or business entity name
Owner of Fictitious Name If An Individual: , , Last First Middle
- OR -
Owner of Fictitious Name If a Business Entity (Corporation, LLC, etc.): Entity Name Florida Document Number: (Only applies to business entity owners) FEI/EIN Number: - (Only applies to business entity owners) FEI/EIN Number Status: Applied For Not Applicable Current
Street Address
City, State	,
Zip Code & Country

Please review the filing for accuracy. If you need to make corrections, do so at this time. The filing information will be added/edited exactly as you have entered it. Once you have submitted the information, your filing cannot be updated, removed, cancelled or refunded.

I the undersigned, being an owner in the above fictitious name, certify that the information indicated on this form is true and accurate. I further certify that the fictitious name to be registered has been advertised at least once in a newspaper as defined in chapter 50, F.S., in the county where the principal place of business is located. I understand that the electronic signature below shall have the same legal effect as if made under oath and I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s. 817.155, F.S.
Owner Signature
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Florida Department of State, Division of Corporations