K SOLE MBR XXX-XX Principal Business Activity What your business/organization does: HEALTH CARE Principal products/services: DENTIST Additional LLC Information Owns a 55,000 pounds or greater highway motor vehicle: NO EFTA00573434 Involves gambling/wagering: NO Involves alcohol, tobacco or firearms:

of doing business in California? ,,,,,, ,,, ,,,,,,,,, ,,, ,,,,,,,,, ,,, ,,,,,,,,, ,,, ,,,,,,,,, ,,, ,,,,,,,,, ,,, ,,, • O Yes M No Single Member LLC Information and Consent • Complete only if the LLC is disregarded. caul II • $SN Sole Owner's name (as shown on owner's return) 0 Street Address, City. Sta

LC previously operated outside California', (2) Is this the first year of doing business in California/ • • @Yes 0 Yes 0 No No Single Member LLC Information and Consent - Complete only if the LLC is tfisregarded. • Federal 11NISSN Sole Owner's name (as shown en owners return) FEIN/CA Corp noiCA SOS Fie