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NAME - AUTHORIZED REPRESENTATIVE SIGNATURE OFFICIAL TITLE DATE IU Type Check One SIU Inspector Date Make check for 510. - D. Business Ownership Examples 1- 2- Example DBA ABCD Dentistry i.e. business name Officer1 Audra Kiper President Chief Financial Officer DBA Dental World i.e. business name Officer1 John Doe Partner Officer2 Mary Smith General Partner 3- 4- DBA John s General Dentistry i.e. business name Owner DBA Children Dentistry i.e. business name Officer2 Tricia Harris The City of...
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