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Assumed Business Name-Amendment or Cancellation (Oregon)

This is to amend or cancel an assumed business name registration in Oregon. The form provided here is simply a sample of what the actual Form CR102 looks like.

CR102 (Rev. 3/2001)

Phone: (503) 986-2200
Fax: (503) 378-4381
Secretary of State
Corporation Division
255 Capitol St. NE, Suite 151
Salem, OR 97310-1327

For office use only

Check the appropriate box below:

____ AMENDMENT (Complete all items)

____ CANCELLATION (Complete only 1, 3, 8, 9)

Registry Number: ________________________________

Attach Additional Sheet if Necessary
Please Type or Print Legibly in Black Ink

Assumed Business Name--Amendment or Cancellation

1) ASSUMED BUSINESS NAME ____________________________________

2) DESCRIPTION OF BUSINESS ___________________________________

____ CHECK HERE TO INDICATE ON YOUR REGISTRATION THAT YOU DO NOT WANT MAIL SOLICITATION. PLEASE NOTE, THERE IS NO OBLIGATION ON THE PART OF PERSONS USING OUR LISTS TO REFRAIN FROM MAILING SOLICITATIONS. THE MARK IS SIMPLY INFORMATIONAL. ORS 56.022

3) PRINCIPAL PLACE OF BUSINESS

Street Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

4) AUTHORIZED REPRESENTATIVE (One name only)

_________________________________________________

____ Continuing ____ New (For AMENDMENT only)

5) MAILING ADDRESS FOR AUTHORIZED REP

Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

6) REGISTRANTS (List names and street addresses of registrants. Attach a separate sheet if necessary.) (All new registrants must be listed. If registrants are withdrawing, both continuing and withdrawing registrants must be listed.)

New Registrants

Name ____________________________________

Street Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

Name ____________________________________

Street Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

Continuing Registrants

Name ____________________________________

Street Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

Name ____________________________________

Street Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

Withdrawing Registrants

Name ____________________________________

Street Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

Name ____________________________________

Street Address ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

7) COUNTIES ____ Baker ____ Crook ____ Harney ____ Lake ____ Morrow ____ Union ____ Benton ____ Curry ____ Hood River ____ Lane ____ Multnomah ____ Wallowa ____ Clackamas ____ Deschutes ____ Jackson ____ Lincoln ____ Polk ____ Wasco ____ Clatsop ____ Douglas ____ Jefferson ____ Linn ____ Sherman ____ Washington ____ Columbia ____ Gilliam ____ Josephine ____ Malheur ____ Tillamook ____ Wheeler ____ Coos ____ Grant ____ Klamath ____ Marion ____ Umatilla ____ Yamhill ____ All Counties (Statewide)

8) SIGNATURES (All new registrants must sign. On an AMENDMENT, the Authorized Representative may make any changes necessary with the exception of signing for new Registrants. If any registrants are WITHDRAWING, withdrawing Registrants or Authorized Representative must sign. If there is a change of Authorized Representative, all registrants must sign. For a CANCELLATION, the Authorized representative or All Registrants must sign.)

____________________________________

____________________________________

9) CONTACT NAME DAYTIME PHONE NUMBER - INCLUDING AREA CODE

____________________________________

FEES

Required Filing Fee $ 10
$2 for each county $ ________
Confirmation copy (optional) $5
TOTAL (nonrefundable) $ ________

Please make check payable to "Corporation Division."

NOTE: Filing fees may be paid with VISA or MasterCard. The card number and expiration date should be submitted on a separate sheet for your protection.

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