Notification of Changes for Business Entity
General Information
Business Entity Name:	FDA SERVICES, INC
Incorporation / Formation Date:
FEIN:	59-2963601
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	FL
County:	LEON
Business Address
Address 1:	545 JOHN KNOX RD
Address 2:	SUITE 201
City:	TALLAHASSEE
State:	FL
Zip:	32303
Phone:	8506812966
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	545 JOHN KNOX RD
Address 2:	SUITE 201
City:	TALLAHASSEE
State:	OH
Zip:	32303
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	CSC
Title:	AUTHORIZED SUBMITTER
Phone Number:	8009279801
Email Address:	BLINSURANCE@CSCGLOBAL.COM