Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696589158912.pdf (United States)
Secretary of State - Corporation Division - 255 Capitol St. NE, Suite 151 - Salem, OR 97310-1327 - sos.oregon.gov/business - Phone: (503) 986-2200 Complete only the sections that you are updating.

To review current information, please go to: sos.oregon.gov/bizsearch Fax: (503) 378-4381 Assumed Business Name - Amendment REGISTRY NUMBER: In accordance with Oregon Revised Statute 192.410-192.490, the information on this application is public record.
We must release this information to all parties upon request and it will be posted on our website.

For office use only Please Type or Print Legibly in Black Ink.

Attach Additional Sheet if Necessary.

1.

CURRENT BUSINESS NAME: 2.

NEW BUSINESS NAME: (If changed, $50 fee required) 3.

DESCRIPTION OF BUSINESS: 4.

PRINCIPAL PLACE OF BUSINESS: (Street Address, City, State, Zip) 5.

NAME OF AUTHORIZED REPRESENTATIVE: (One name only) CONTINUING or NEW 6.

MAILING ADDRESS OF AUTHORIZED REPRESENTATIVE: 7.


REGISTRANTS/OWNERS: (List name and publicly available street address of new registrants)(Attach separate sheet if needed) a.

NEW REGISTRANTS/OWNERS: Street Address City State Zip b.

WITHDRAWING REGISTRANTS/OWNERS: 8.

CURRENT REGISTRANTS/OWNERS ADDRESS CHANGE ONLY: (This section is only for registrant address changes)(Attach separate sheet if needed) Registrant Name Street Address City State Zip 9.
COUNTIES: ALL COUNTIES (Statewide) Baker Benton Crook Curry Clackamas Deschutes Clatsop Columbia Coos Douglas Gilliam Grant Harney Hood River Jackson Jefferson Josephine Klamath Lake Lane Lincoln Linn Malheur Marion Morrow Multnomah Polk Sherman Tillamook Umatilla Union Wallowa Wasco Washington Wheeler Yamhill 10.

SIGNATURE(S): New Registrants must sign.

If any Registrants are WITHDRAWING, withdrawing Registrants or Authorized Representative must sign.
I declare as an authorized signer, under penalty of perjury, that this document does not fraudulently conceal, obscure, alter, or otherwise misrepresent the identity of any person including officers, directors, employees, members, managers or agents.

This filing has been examined by me and is, to the best of my knowledge and belief, true, correct and complete.

Making false statements in this document is against the law and may be penalized by fines, imprisonment, or both.
Signature: Printed Name: CONTACT NAME: (To resolve questions with this filing) FEES PHONE NUMBER: (Include area code) Assumed Business Name - Amendment (11/17) If Changing Business Name $50 No Fee For Other Changes Processing Fees are nonrefundable.

Please make check payable to "Corporation Division".

Free copies are available at sos.oregon.gov/business using the Business Name Search program.