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Certificate of Assumed Name (New York)

This is a certificate of an assumed name of a corporation in New York. The form provided here is simply a sample of what the actual Form DOS-1338 looks like.

DOS-1338 (7/99)

NYS Department of State
Division of Corporations, State Records and UCC
41 State Street, Albany, NY 12231-0001
www.dos.state.ny.us

Certificate of Assumed Name

Pursuant to General Business Law, §130

1. NAME OF ENTITY ____________________________________

2. BUSINESS FORMED UNDER (CHECK ONE):

____ Business Corporation Law

____ Limited Liability Company Law

____ Education Law

____ Not-for-Profit Corporation Law

____ Insurance Law

____ Revised Limited Partnership Act

____ Other (specify law): ____________________________________

3. ASSUMED NAME ____________________________________

4. PRINCIPAL PLACE OF BUSINESS IN NEW YORK STATE (MUST BE NUMBER AND STREET. IF NONE, INSERT OUT-OF-STATE ADDRESS)

____________________________________

____________________________________

____________________________________

5. COUNTIES IN WHICH BUSINESS WILL BE CONDUCTED UNDER ASSUMED NAME

____ ALL COUNTIES (if not, circle county[ies] below)
Albany
Allegany
Bronx
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Fulton
Genesee
Greene
Hamilton
Herkimer
Jefferson
Kings
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
New York
Niagara
Oneida
Onondaga
Ontario
Orange
Orleans
Oswego
Otsego
Putnam
Queens
Rensselaer
Richmond
Rockland
St. Lawrence
Saratoga
Schenectady
Schoharie
Schuyler
Seneca
Steuben
Suffolk
Sullivan Yates
Tioga
Tompkins
Ulster
Warren
Washington
Wayne
Westchester
Wyoming

6. NUMBER AND STREET ADDRESS(ES) AND COUNTY OF EACH BUSINESS LOCATION WITHIN NEW YORK STATE (USE CONTINUOUS SHEET, IF NEEDED)

____ No New York State Business Location

____________________________________

____________________________________

____________________________________

INSTRUCTIONS FOR SIGNATURE: If corporation, by an officer; if limited partnership, by a general partner; if limited liability company, by a member or manager or by an attorney-in-fact or authorized person for such corporation, limited partnership, or limited liability company.

Name and Title ____________________________________

Signature ____________________________________



CERTIFICATE OF ASSUMED NAME

OF

____________________________________

Pursuant to §130, General Business Law

Filed by: ____________________________________ (Name)

____________________________________ (Mailing address)

____________________________________ (City, State and ZIP code)

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