Office of the Clark County Clerk Please Select One:
Lynn Marie Goya
New Application
Ren
ewal of existing Fictitious Firm Name
Certificate of Business: Fictitious Firm Name
Please Print or Type
The
expiration date for such certificates shall expire after five years from the date of filing.
The undersigned do/does hereby certify that they are conducting business in Clark County, Nevada, under the
Fict
itious Firm Name: ______________________________________________________________________________
Mail
ing Address: __________________________________________________________________________________
(Mailing Address for notification of renewal) Mailing Address City, State, Zip
Ow
ner (Sole Proprietor or
Registered Legal Entity): __________________________________________________________________________
(Must print name exactly as it is registered with the Nevada Secretary of State)
and th
at said firm is composed of the following person(s) whose name(s) and address(es) are as follows:
Signed By: _________________________________________ _____________________________________________
Full Name of Authorized Signer Signature Date
________________________________________________________________________________________
Street Address of Business or Residence City, State, Zip
Signed By
: _________________________________________ _____________________________________________
(Use if needed) Full Name of Authorized Signer Signature Date
_____
___________________________________________________________________________________
Street Address of Business or Residence City, State, Zip
By s
igning above, I declare (or affirm), under penalty of perjury, that all statements made in this document are
true, and that I have authority to sign on behalf of and to bind the above named business/legal entity to a contract.
Fo
r additional signatures, please use additional pages
STA
TE OF _________________________
SS:
COUNTY OF _______________________
This instrument was acknowledged before me on _____________________________________________________________
(Date)
by __________________________________________________________________________________________________
(Name of individual(s) whose signature(s) is/are being notarized)
__________________________________________________
Signature of Notary Public/Deputy Clerk
Mail to: Lynn Marie Goya, County Clerk, Attn. FFN, Box 551604, Las Vegas NV 89155-1604
Include: Filing Fee of $25.00 payable to County Clerk, completed certificate and a self-addressed stamped envelope.
Rev 08/2019
