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ATTN: To ensure that your payment is processed in a timely manner, please confirm that the following originator id for ACH Debit 1522077581 is on file with your bank.

Application for Fictitious Name

Pursuant to the provisions of the Arkansas Business Corporation Act (Act 958 of 1987), the undersigned corporation hereby applies for the use of a fictitious name and submits herewith the following statement:

1. The fictitious name under which the business is being, or will be, conducted by this corporation is:
2. The character of the business being, or to be, conducted under such fictitious name is:
3. a. The corporation name of the applicant and its date of qualification in Arkansas:
/ / (mm/dd/yyyy)
b. The State of incorporation is:
c. The location (city and street address) of the registered office
of the applicant corporation in Arkansas is:
Street Address:
Signature of the Chairman of the Board, President or other
officers (if directors have not been selected, the incorporator may execute):
Street Address:
2 Letter Abbreviation ZIP: -
I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days.

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