DONNA GORMAN SILBERMAN
Acting County Clerk
COUNTY OF ROCKLAND
OFFICE OF THE COUNTY CLERK
1 SOUTH MAIN STREET, SUITE 100
NEW CITY, NEW YORK 10956
Phone (845) 638-5070 Fax (845) 638-5647
My full name and place of residence is:
I HEREBY CERTIFY that I am conducting or transacting business in Rockland County as a Sole Proprietor,
pursuant to Section 130 of the New York State General Business Law, under the name or designation and at the
I FURTHER CERTIFY that I am successor in interest to:____________________________________.
(Name of former owner of business, if applicable.)
I FURTHER CERTIFY that I am _________ years of age (if under 18).
____Medical - Home Care Services
____Professional - Technical Services
Please designate the type of business:
____Entertainment - Recreation
____Finance - Insurance Service
____Home Improvement Services
IN WITNESS WHEREOF, I hereby sign this certificate the ______ day of _________________, 20___.
ACKNOWLEDGEMENT IN NEW YORK STATE (RPL 309-a)
State of New York
County of Rockland ss.:
the undersigned, personally appeared______________________________
personally known to me or proved to me on the basis of satisfactory evidence
to be the individual whose name is subscribed to the within instrument and
acknowledged to me that he/she executed the same in his/her capacity, and that
by his/her signature on the instrument, the individual, or the person upon their
behalf of which acted, executed the instrument.
(Signature and office of individual taking acknowledgement)