PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Application for Certificate of Authority (15 Pa.C.S.) Foreign Business Corporation (§ 4124) Foreign Nonprofit Corporation (§ 6124) Name Document will be returned to the name and address you enter to the left. Address City State Zip Code Fee: $250 In compliance with the requirements of the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated associations), the undersigned, hereby states that: 1. The name of the corporation is: 2. Complete only when the corporation must adopt a corporate designator for use in Pennsylvania. The name which the corporation adopts for use in this Commonwealth is: 3. If the name set forth in paragraph 1 or 2 is not available for use in this Commonwealth, complete the following: The fictitious name which the corporation adopts for use in transacting business in this Commonwealth is: The corporation shall do business in Pennsylvania only under such fictitious name pursuant to the attached resolution of the board of directors under the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated associations) and the attached form DSCB:54-311 (Application for Registration of Fictitious Name). 4. The name of the jurisdiction under the laws of which the corporation is incorporated is: 5. The address of its principal office under the laws of the jurisdiction in which it is incorporated is: Number and street City State Zip American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-4124/6124-2 6. The (a) address of this corporation’s proposed registered office in this Commonwealth or (b) name of its commercial registered office provider and the county of venue is: (a) Number and street City State Zip Count y (b) Name of Commercial Registered Office Provider c/o: County 7. Check one of the following: Business Corporation: The corporation is a corporation incorporated for a purpose or purposes involving pecuniary profit, incidental or otherwise. Nonprofit Corporation: The corporation is a corporation incorporated for a purpose or purposes not involving pecuniary profit, incidental or otherwise. IN TESTIMONY WHEREOF, the undersigned corporation has caused this Application for Certificate of Authority to be signed by a duly authorized officer thereof this day of , . Name of Corporation Signature Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB: 15-4124/6124 Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Web site: www.dos.state.pa.us/corps Instructions for Completion of Form: A. Typewritten is preferred. If not, the form shall be completed in black or blue-black ink in order to permit reproduction. The filing fee for this form is $250 made payable to the Department of State. B. Under 15 Pa.C.S. § 135(c) (relating to addresses) an actual street or rural route box number must be used as an address, and the Department of State is required to refuse to receive or file any document that sets forth only a post office box address. C. The following, in addition to the filing fee, shall accompany this form: (1) One copy of a completed form DSCB:15-134A (Docketing Statement). (2) Any necessary copies of form DSCB:17.2.3 (Consent to Appropriation of Name). If Letter of Consent cannot be obtained, the applicant may file in the Department a resolution of its board of directors adopting a fictitious name for use in transacting business in the Commonwealth of Pennsylvania which fictitious name is distinguishable upon the record to the name of any conflicting profit or nonprofit corporation or other association and that is otherwise available for use by a domestic business or nonprofit corporation. See 15 Pa.C.S. §§ 4123(b)(1)(i) and 6123(b)(1)(i). An additional filing fee of $70 shall accompany form DSCB:54-311 (Application for Registration of Fictitious Name). (3) Any necessary governmental approvals. If required governmental approvals for the use of the name cannot be obtained, the applicant may file in the Department a resolution of its board of directors adopting a fictitious name that is otherwise available for use by a domestic business or nonprofit corporation. See 15 Pa.C.S. §§ 4123(b)(2) and 6123(b)(2). D. Where the name of the corporation does not comply with 19 Pa. Code § 23.3 (relating to business corporation names) or with 19 Pa. Code § 41.3 (relating to nonprofit corporation names) the corporation must adopt a corporate designator (corporation, incorporated, limited, etc. or abbreviation) for use in Pennsylvania and set forth the resulting name in Paragraph 2. Otherwise Paragraph 2 should remain blank. See also 19 Pa. Code § 17.41 (relating to foreign association names). E. The corporation is required by 15 Pa.C.S. § 4124(b) or by 15 Pa.C.S. § 6124(b) (relating to advertisement) to advertise its intention to apply or its application for a Certificate of Authority. Proofs of publication of such advertising should not be submitted to, and will not be received by or filed in, the Department, but should be filed with the minutes of the corporation. F. This form and all accompanying documents shall be mailed to the address stated above. Under 15 Pa.C.S. § 4125 or under 15 Pa.C.S. § 6125 upon the filing of this form the applicant corporation shall be deemed to hold a Certificate of Authority, and no actual certificate will be issued to the applicant by the Department. American LegalNet, Inc. www.FormsWorkFlow.com