Certificate of Persons Conducting Business
Under an Assumed Name
I (We) do hereby certify that I am (we are) or intend to operate a business under the following
assumed or designated name:
Name of Business ____________________________________________________________
Business Address: ___________________________________________________________
___________________________________________________________
Telephone Number: ___________________________________________________________
And I (we) certify that the true and full name(s) of the person(s) with an interest in the
conduction or transaction of business under this name is (are) as follows:
Name __________________________ Mailing Address ______________________________
_____________________________
Name___________________________ Mailing Address ______________________________
______________________________
This certificate being executed in compliance with the provisions of Act 11 of 1943 (A.C.A. 4-
70-203 et. seq.)
Signature ________________________________________ Date ________________
Signature ________________________________________ Date ________________
Acknowledgement
State of Arkansas
County of Sebastian
On this ______day of _______________, 20__ before me, the undersigned officer, personally
appeared, _________________________________________, known to me (or satisfactorily
proven) to be the person(s) described in the foregoing certificate. And acknowledged that he/she
executed the same in the capacity therein stated and for purposes therein contained.
Subscribed and sworn to before me this ______day of _________________, 20__.
(seal) _________________________________
Notary Signature
_____________________ Expiration Date
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