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2. I hereby attest that I am not required to register my business with the Secretary of State of Florida under the Fictitious Name Act for one of the following:
4. Select one

   1. Doing business under my legal name.
   2. Business is incorporated and registered with the Secretary of State (Inc., LLC, Co., etc) and not using a DBA.

   1. Business name is a registered trademark.
   2. Exempt due to being licensed by DBPR/DOH,

   1. Federally chartered Bank.
   2. Other:
6. If you selected "Other," explain*
8. Name of Business
9. Business Address
11. Signature of Business Owner*
12. Date:
14. Print Owner's Name
16. FEIN #/SSN*
    Federal I.D. # (or) Social Security Number (for individuals)
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit Submit and Print

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