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APPLICATION FOR REGISTRATION OF FICTITIOUS NAME <br /> Note: Acknowledgements /certificates will be sent to the address In Section 1 only. ATTACHMENT <br /> 1 Treelawn Builders <br /> Fictitious Name to be Registered (ese Nutructione it name includes "Corp' or "Inc') <br /> P.O. Box 506 <br /> C <br /> Mailing Address of BYSlnase `r ] _ ],J 7 Brooksville Florida 34605 -0506 ^^�""'ff <br /> co City State Zip Code <br /> 3. Florida County of principal place of business: Hemando <br /> (see instructions it more than one county) This space for office use only <br /> A. Owner(s) of Fictitious Name If Indivldual(s): (Use an attachment If necessary): <br /> 1. Beasley Paul C. 2. <br /> Last First MA. Last First M.I. <br /> P.O. Box 506 <br /> Address Address <br /> Brooksville Florida 34605 -0506 <br /> City State Zip Code City State Zip Code <br /> N <br /> O • B. Owner(s) of Fictitious Name If other than an Individual: (Use attachment if necessary): <br /> 1. 2. <br /> co Entity Name Entity Nana <br /> Address Address <br /> City State Zlp Code City State Zip Code <br /> Florida Registration Number Florida Registration Number <br /> FEI Number: FEI Number: <br /> ❑ Applied for ❑ Not Applicable ❑ Applied for ❑ Not Applicable <br /> I (we) the undersigned, being the sole (all the) party(ies) owning interest in the above fictitous.name, certify that the information indicated on this Corm <br /> is true rate. In acco rdance with Se 885.09, F.S., I (we) understand that the signature(s) below shall have the same legal effect as t <br /> • ma nder math (At Leas 0n Si Rrired) <br /> Signature o Owner Signature of Owner Date <br /> N <br /> Phone Number: (352) 796 -2433 Phone Number. <br /> FOR CANCELLATION COMPLETE SECTION 4 ONLY: <br /> FOR FICTITIOUS NAME OR OWNERSHIP CHANGE COMPLETE SECTIONS 1 THROUGH 4: <br /> er I (we) the undersigned, hereby cancel the fictitious name <br /> , which was registered on and was assigned <br /> • registration number <br /> Signature of Owner Date Signature of Owner Date <br /> Mark the applicable boxes ❑ Certificate of Status — $10 ® Certified Copy — $30 <br /> NON - REFUNDABLE PROCESSING FEE: $50 <br /> Single CR4E001 (11/03) <br />