KNOW ALL MEN BY THESE PRESENTS:
That the undersigned does hereby certify the following:
1. The undersigned is transacting or proposes to transact
     business in the State of  [state], under the fictitious name 
     of [name]. 
2. The principal place of said business is located at [address].
3. The full name of the undersigned is [name].
4. The place of residence of the undersigned is
    [complete address].

Dated: 


________________________________________
(clearly print name after signature)

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