Business Certificate Registration

Westchester County Clerk Timothy C. Idoni BUSINESS CERTIFICATE REGISTRATION I HEREBY CERTIFY that I am conducting or transacting business in Westchester County, pursuant to Section 130 of the New York State General Business Law, under the name or designation (Please Print or Type) and at the address of: Business Name: Business Address: My full name and place of residence is: Name: Address: (Please Print or Type) I FURTHER CERTIFY that I am successor in interest to ___________________________________________________. (Name of former owner of business, if applicable.) I FURTHER CERTIFY that I am _____ years of age (if under 18). Please designate the type of business: Consultant Services Educational Services Entertainment-Recreation Finance-Insurance Services Home Improvement Services Medical ­ Home Care Services Professional ­ Technical Services Real Estate Services Retail Trade Wholesale Trade Other ________________________________________________________ IN WITNESS WHEREOF, I hereby sign this certificate the ______day of ____________20_____ _______________________________________ ACKNOWLEDGEMENT IN NEW YORK STATE (RPL 309-a) State of New York County of Westchester On personally appeared }ss.: before me, the undersigned, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon their behalf of which the individual acted, executed the instrument. (Signature and office of individual taking acknowledgement) Rev. 5/08 American LegalNet, Inc. www.FormsWorkflow.com