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Office of the Minnesota Secretary of State
Assumed Name I Certificate of Assumed Name
Minnesota Statutes, Chapter 333

Read the instructions before completing this form.

Note: An Annual Renewal is required to be filed once every calendar year, beginning in the calendar year
following the original filing with the Secretary of State.
The filing of an assumed name does not provide a user with exclusive rights to that name. The filing is required for
consumer protection in order to enable consumers to be able to identify the true owner of a business.
I. List the exact assumed name under which the business is or will be conducted: (Required)

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2. Principal Place of Business: (Required)

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State

Street Address (A PO Box by itself is not acceptable)

Zip

3. List the name and complete street address of all persons conducting business under the above Assumed Name, OR if
an entity, provide the legal corporate, LLC, or Limited Partnership name and registered office address: (Required)
Note: A PO Box by itself is not acceptable. Attach additional sheet(s) if necessary.

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Name

Street

City

Name

Street

Name

Street

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State

Zip

City

State

Zip

City

State

Zip

4. I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the
person( s) whose signature would be required who has authorized me to sign this document on his/her behalf, or in both
capacities. I further certify that I have completed all required fields, and that the information iri this document is true and
correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document
I am subject to the penalti s ofperju as set forth in Section 609.48 as if! had signed this document under oath.

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Signature Only one nameholder or an authorized agent is required to sign)

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Print Name and Title

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Date

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Email Address for Official Notices
Enter an email address to which the Secretary of State can forward official notices required by law and other notices:.

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~ Check here to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law.

 Office of the Minnesota Secretary of State
Assumed Name I Certificate of Assumed Name
Minnesota Statutes, Chapter 333

List a name and daytime phone number of a person who can be contacted about this form:

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Contact Name

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Phone Number

Entities that own, lease, or have any financial interest in agricultural land or land capable of being farmed
must register with the MN Dept. of Agriculture's Corporate Farm Program.

Minnesota Business Snapshot
To better serve Minnesotans, the Secretary of State's Office has created the "Minnesota Business Snapshot," a short and simple survey
produced with the input of business owners, business organizations, non-profits, and researchers from across the state. These five
questions will take less than three minutes to complete, and you may answer any or all of them. There is no penalty if you choose not to
provide this information. However, the answers you do provide will create a useful pool of information for potential customers and
inforni the analysis of our quarterly "Minnesota Economic and Business Condition Reports". We do not independently verify the answers
applicants provide. Again, this survey is voluntary and the answers are considered public data. Thank you.
1. (Select up to one) - How many Minnesota - based full time employees (or FTE equivalents) does this entity currently have?

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0
0
0
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6-50
51-200
201-500
Over500

2. (Select all that apply) - Does the owner or a member of the ownership group of this entity self-identify as a member of any of the
following communities?

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D
D
D

Woman
Member of a community of color
Veteran
Member of a disability community
Member of an immigrant community

3. (Select up to one) - Using NAICS codes below, please select the cod.e that best describes this entity. If you believe this entity falls
into more than one category, please select the category that generates the majority of the entity's revenue.

D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D

•

D
D
D

Agriculture, Forestry, Fishing and Hunting (Code 11)
Mining (Code 21)
Utilities (Code 22)
Construction (Code 23)
Manufacturing (Codes 31-33)
Wholesale Trade (Code 42)
Retail Trade (Codes 44-45)
Transportation and Warehousing (Codes 48-49)
Information (Code 51)
Finance and Insurance (Code 52)
Real Estate Rental and Leasing (Code 53)
Professional, Scientific, and Technical Services (Code 54)
Management of Companies and Enterprises (Code 55)
Administrative and Support and Waste Management and Remediation Services (Code 56)
Educational Services (Code 61)
Health Care and Social Assistance (Code 62)
Arts, Entertainment, and Recreation (Code 71)
Accommodation and Food Services (Code 72)
Other Services (except Public Administration) (Code 81)
Public Administration (Code 92)

 Office of the Minnesota Secretary of State
Assumed Name I Certificate of Assumed Name

MinnesotaStatutes, Chapter 333

4. (Select up to one) Is this entity a full time or part time endeavor for those primarily responsible for operating this entity?

D Full time

l!l!IPart time
5. (Select up to one) - If applicable, what were this entity's gross revenues for the past year?
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$0 - $10,000
0 $ I 0,00 I - $50,000
0 $50,00 I - $250,000
0 $250,001 - $1M
D Over $1M

AssumedNameRegistrationRev.9/19/2016

 Work Item 1025426100062
Original File Number 1025426100062
STATE OF MINNESOTA
OFFICE OF THE SECRETARY OF STATE
FILED
08/02/2018 11:59 PM

Steve Simon
Secretary of State