(a) The legal name of the entity utilizing the fictitious business name;
(b) The fictitious business name with respect to which the statement of withdrawal relates;
(c) That the entity will no longer transact business in this state under the fictitious business name;
(d) An acknowledgement that the applicant understands the fictitious business name registration will no longer be effective upon the filing of the statement of withdrawal; and
(e) The signature of the withdrawing registrant.
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