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Vided) ADDITIONAL COMPANY NAME (Abbreviate if longer than spaces provided) PREVIOUS MLS NUMBER IF A CHANGE ADDRESS (Number and Street) CITY STATE ZIPCODE FOR MIC TRANSACTIONS ONLY: TEL. PREVIOUS ZIPCODE IF A CHANGE NEW COMPANY ACTIVE COMPANY OUT OF BUSINESS U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5093 (Rev. 6-04) PREVIOUS EDITIONS ARE OBSOLETE PAGE 2 OF CG-5093 (Rev. 6-04) INSTRUCTIONS DATE: Fill in the current date. ACTION CODE: For an add transaction, fill in every field. For a BS.

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