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APPLICATION FOR <br /> REGISTRATION OF FICTITIOUSNAME <br /> FILED <br /> 1 EXCHANGE CLUB C . A . S . T . L . E . DIVISION OF CORPORATIONS <br /> Fictitious Name to be Registered TALLAHASSEE , FLORIDA <br /> 08 - 09 - 93 0003 023 * * * 80 , 00 <br /> C9222 1 CDaC". 1 � � <br /> 0 2. 828 South U . S . Highway # 1 <br /> «. Mailing Address of Business <br /> U <br /> d <br /> 3 . County of St . Lucie <br /> 4 . City of Ft . Pierce , Florida 34950 <br /> 5. FEI Number: ' N / A Zip Code <br /> This space for office use only <br /> A. Owner(s) of Fictitious Name If Individual(s) (use additional sheets if necessary): <br /> 1 . 2. <br /> Last First M.1, Last First M. I. <br /> Address Address <br /> City State Zip Code City State Zip Code <br /> �+ SSI# SS# <br /> 0 B . Owner(s) of Fictitious Name If Corporation(s) (use additional sheets if necessary). <br /> The Exchange Club Center For the Prevention of <br /> n 1 Child Abuse of the Treasure Coast , Ilic . <br /> Corporate Name Corporate Name <br /> 828 South U . S . Highway # 1 <br /> Address Address <br /> Ft . Pierce , FL 34950 <br /> City State Zip Code City State Zip Code <br /> Corporate Document Number: 75(a 115 Corporate Document Number: <br /> FEI Number: _j 9 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 fictitious name, certify that the-information Indicated <br /> on this form Is true and accurate. I (we) further certify that the fictitious name shown in Section 1 of this form has .been advertised at <br />least <br /> `7 once in a newspaper as defined in chapter 50, Florida Statutes, in the county where the applicant 's principal place of business is located. <br /> I (we) understand that the signature(s) below shall have the same legal effect as If gnade under oath. (At Least One Signature Required) <br /> o Exchange Club Center - - for the Prevention or <br /> ✓ he Treasure Coast , Inc . by Chuck Kitzmiller , Pres . <br /> MIS a%m <br /> A Signature of Owner Date Signature of Owner Date <br /> Phone Number: 402 - 465 - 15011 Phone Number. <br /> FOR CANCELLATION COMPLETE SECTION 4 ONLY: <br /> FOR FICTITIOUS NAME OWNERSHIP CHANGE COMPLETE SECTIONS 1 THROUGH 4 : <br /> 7 I (we) the undersigned , hereby cancel the fictitious name <br /> c <br /> 0 <br /> U , which was registered on and was assigned <br /> registration number <br /> Signature of Owner Date Signature of Owner Date <br />