Notification of Changes for Business Entity
General Information
Business Entity Name:	DOSTAL & KIRK, INC.
Incorporation / Formation Date:
FEIN:	34-0947801
Ohio License Number:	3896
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CRAWFORD
Business Address
Address 1:	120 S. SANDUSKY AVE.
Address 2:
City:	BUCYRUS
State:	OH
Zip:	44820
Phone:	419-562-7756
Fax:
Business Web Site Address:	WWW.DOSTALKIRK.COM
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 646
Address 2:
City:	BUCYRUS
State:	OH
Zip:	44820
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	SCHARER INSURANCE
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)	NO
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?	NO
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:	MICHAEL D. DOSTAL
Title:	SEC/TREAS
Phone Number:	419-562-7756
Email Address:	MDOSTAL@DOSTALKIRK.COM