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Office of the Minnesota Secretary of State
Name Reservation

I Request

for Reservation of Name

Minnesota Statutes, Chapter 302A. ll 7, 317 A. II 7, 322C 0/09 or 321.109

Read the instructions before completing this form.
Filing Fee: $55 for expedited service in-person and on line filings, $35 ifby mail

I hereby request the Secretary of State to reserve the name listed below. I understand that the name reservation
does not register the business name, and is valid for twelve months from the date on which it is filed. The name
reservation may be renewed for additional twelve month periods, pursuant to Minnesota Statutes, sections
302A. I 17, 317 A.117, 322C.0109 or 321. 109.
I, Desired Name: (Required)
2. Reserved for: (Required)

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Note: If this name is reserved for an organization not yet formed, list the individual who will be signing the
documents, which will be submitted at the time of the organization of the business.

3. List the complete street address of the individual or organization who this name is being reserved for: (Required)

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

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City

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Zip

4. The applicant hereby states that the proposed name holder is:
a) A person doing business in this state under that name or a deceptively similar name;
b) A person intending to form an entity under Chapter 302A, 317 A, 322C or 321;
c) A domestic corporation, limited liability company or limited partnership intending to change its name;
d) A foreign corporation, foreign limited liability company or foreign limited partnership intending to make
application for a Certificate of Authority to transact business or register in this state;
e) A foreign corporation, foreign limited liability or foreign limited partnership authorized to transact business in this
state and intending to change its name;
f) A person intending to incorporate a foreign corporation, or foreign limited liability company and intending to have
the foreign corporation, or foreign limited liability company make application for a Certificate of Authority to transact
business in this state; a person registering as a foreign limited partnership; or
g) A foreign corporaiion, foreign limited liability company or foreign limited partnership doing business under that
name or a name deceptively similar to that name in a state other than Minnesota and not described in clauses d, e or f.
5. 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 in this document is true and
correct and in compliance with the applicable chapter of Minnesota Statutes. 1 understand that by signing this document
1 am subject to th,em=itt1es f perjury a set forth in Section 609.48 as if I had signed this document under oath.

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

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Uj Check here to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law.
List a name and daytime phone number of a person who can he contacted about this form:

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Phone Number

 Work Item 1025426100033
Original File Number 1025426100033
STATE OF MINNESOTA
OFFICE OF THE SECRETARY OF STATE
FILED
08/02/2018 11:59 PM

Steve Simon
Secretary of State