North Carolina General Statutes Chapter 66. Commerce and Business § 66-71.11. Forms

1. The assumed business name is: ______________________________

(You may include no more than five (5) assumed business names on this form.)

2. The real name of the person or entity engaging in business under the assumed business name is: __________________________________________________

(Corporations, limited liability companies, limited partnerships must provide the exact name registered with the NC Secretary of State's office and the SOSID number assigned at the time of formation.)

3. The nature/type of the business is: ___________________________________________

4. The street address of the principal place of business is: ___________________________

(Post office boxes are not acceptable.)

5. The mailing address, if different from the street address, is: ________________________

6. The counties where the assumed business name will be used to engage in business are:

___________________________________ (Can indicate all 100 North Carolina counties)

This certificate is signed by the owner/legal representative of the person or entity named above, this _______ day of ____________________, 20_______.

Signature: ___________________________________

Printed/Typed Name: _________________________

Title: ___________________________________

1. The assumed business name previously registered is: ________________________________

2. The real name of the person or entity engaging in business under the assumed business name is: __________________________ (Corporations, limited liability companies, limited partnerships must provide the exact name registered with the NC Secretary of State's office and the SOSID number assigned at the time of formation.)

3. The book and page number of the initial filing that is being amended is: Book _____, Page _____, _______________ County Registry.

4. The identification number assigned to the assumed business name by the Secretary of State (SOSID) is: _________________________________________

5. The current mailing address of the business: __________________________

6. The certificate of assumed business name should be amended by changing the following information:

(Check all that apply and provide new information in the space provided below.):

☐ Change assumed business name

☐ Add real name of person engaging in business under assumed business name

☐ Delete real name of person engaging in business under assumed business name

☐ Change nature of business

☐ Change street address of principal place of business

☐ Change mailing address

☐ Add counties where assumed business name will be used to engage in business

☐ Delete counties where assumed business name will be used to engage in business

7. Provide new information here:

☐ Add: __________________________________

☐ Delete: __________________________________

☐ Change: __________________________________

This certificate is signed by the owner/legal representative of the person or entity named above, this_____ day of ____________________, 20_____.

Signature: __________________________

Printed/Typed Name: ________________

Title: _____________________________