CLERK OF SUPERIOR COURT REGISTRATION OF TRADE NAME

----------------

CLERK

OF

SUPERIOR

COURT

REGISTRATION

OF

TRADE

NAME

(PURSUANT

TO

GA

CODE 10-1-490)

ST

ATE

OF GEORGIA

)

$159.00 FILING

FEE

COUNTY OF COLUMBIA

)

$45.00 PUBLICA

nON

FEE

o NEW

o AMENDMENT o CANCELLA

nON

AFFIDAVIT

OF

BUSINESS

CONDUCTED

UNDER

TRADE

NAME

I/We,

, hereby certify

that

(I

AM) or

(WE

ARE)

the owner(s) of a certain business

in

Columbia

County,

Georgia,

now

being carried

on

as follows:

GEORGIA

TRADE NAME OF: _

ADDRESS:

CONTACT

NUMBER: _

NATURE

OF

BUSINESS: _

The business is

composed

of the following

person/

persons/

corporation:

NAME(S) ADDRESS (ES)

This

day

of

-',20

__

.

By:

_

Print

Name: _

As its: _

Print

Title:

VERIFICATION

Personally

appeared

, before the

undersigned

officer,

who

swears

under

oath

that

the above

and

foregoing statement of

trade

name

registration is

true

and

correct.

This

__

day

of

---J,

20

__

"

Notary Public

Witness Signature

My commission Expires: _

Note:

TIlE

ACT REQUIRES

TIlA

T THIS NOTICE

BE

PUBLISHED

ONCE

A WEEK FOR TWO WEEKS

IN

THE PAPER

WHICH

THE SHERIFF'S

ADVERTISEMENTS ARE PRINTED. This

paper

is the COLUMBIA NEWSTIMES (706) 863-6165; ALSO:

upon

change

of

ownership,

a

new

and

amended

registration

must

be filed. (GA LAWS 1981, P 872)

....

Make

local

check

payable

to

Clerk

of

Court

in

the

amount

of

$204.00 for

filing

and

publication

costs.....