Application For Registration Of Fictitious Name Form - Pennsylvania Department Of State Corporation Bureau Page 2

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DSCB:54-311-2
5. Each entity, other than an individual, interested in such business is (are):
Name
Form of Organization
Organizing Jurisdiction
Principal Office Address
PA Registered Office, if any
Name
Form of Organization
Organizing Jurisdiction
Principal Office Address
PA Registered Office, if any
6. The applicant is familiar with the provisions of 54 Pa.C.S. § 332 (relating to effect of registration) and
understands that filing under the Fictitious Names Act does not create any exclusive or other right in the
fictitious name.
7. Optional): The name(s) of the agent(s), if any, any one of whom is authorized to execute amendments to,
withdrawals from or cancellation of this registration in behalf of all then existing parties to the registration, is
(are):
IN TESTIMONY WHEREOF, the undersigned have caused this Application for Registration of Fictitious
Name to be executed this
day of
,
.
_____________________________________
_____________________________________
Individual Signature
Individual Signature
_____________________________________
_____________________________________
Individual Signature
Individual Signature
_____________________________________
_____________________________________
Entity Name
Entity Name
_____________________________________
_____________________________________
Signature
Signature
_____________________________________
_____________________________________
Title
Title

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