Notification of Changes for Business Entity
General Information
Business Entity Name:	PETFIRST HEALTHCARE LLC
Incorporation / Formation Date:
FEIN:	20-1360022
Ohio License Number:	34659
NPN:	8654037
DBA / Trade Name:
State of Domicile:	IN
County:	CLARK
Business Address
Address 1:	ONE QUARTERMASTER COURT
Address 2:
City:	JEFFERSONVILLE
State:	IN
Zip:	47130
Phone:	812-206-6928
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	ONE QUARTERMASTER COURT
Address 2:
City:	JEFFERSONVILLE
State:	IN
Zip:	47130
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
KEVIN DALE FLETCHER	PRODUCER	17801333	YES		4/15/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	ANTHONY BRENT HINTON
Title:	MANAGER
Phone Number:	812-206-6915
Email Address:	ABHINTON@PETFIRST.COM