Form Dscb:54-311-2 - Registration Of Fictitious Name Page 2
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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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