Form Dscb:15-134a - Docketing Statement Departments Of State And Revenue - 1995

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DOCKETING STATEMENT DSCB:15-134A (Rev 95)
BUREAU USE ONLY:
DEPARTMENTS OF STATE AND REVENUE
Dept. of State Entity Number
FILING FEE: NONE
Revenue Box Number
Filing Period
Date 3 4 5
SIC
Report Code
This form (file in triplicate) and all accompanying documents shall be mailed to:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF STATE
CORPORATION BUREAU
P.O. BOX 8722
HARRISBURG, PA 17105-8722
Check proper box:
Pa. Business-stock
Pa. Business-nonstock
Pa. Business-Management
Pa. Professional
Pa. Business-statutory close
Pa. Business-cooperative
Pa. Nonprofit-stock
Pa. Nonprofit-nonstock
Foreign-business
Foreign-nonprofit
Motor Vehicle for Hire
Insurance
Foreign-Certificate of Authority to D/B/A
Business Trust
Pa. Limited Liability Company
Pa. Restricted Professional Limited Liability Company
Foreign Limited Liability Company
Foreign Restricted Professional Limited Liability Company
Association registering as a result of (check box):
Incorporation (Pa.)
Domestication
Consolidation
Authorization of a foreign association
Division
Summary of Record
Organization (Pa.)
1. Name of association:
___________
_____________
2. Location of (a) initial registered office in Pennsylvania or (b) the name and county of the commercial registered office provider:
(a)
____________
Number and Street/RD number and Box
City
State
Zip code
County
(b) c/o:
____________
Name of commercial registered office provider
County
3. State or Country of Incorporation/Organization:
4. Specified effective date, if applicable: ________________________
5. Federal Identification Number:
6. Describe principal Pennsylvania activity to be engaged in, within one year of this application date:
____
____________
_
____________

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