PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Application for Registration of Name Nonqualified Foreign Corporation (15 Pa.C.S.) Business Corporation (§ 4131) Nonprofit Corporation (§ 6131) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $70 In compliance with the requirements of the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated associations), the undersigned nonqualified foreign corporation, desiring to register its name with the Department of State under 54 Pa.C.S. Ch. 5 (relating to corporate and other association names), hereby states that: 1. The name of the corporation is: 2. The address of the corporation is: Number and street City State Zip County IN TESTIMONY WHEREOF, the undersigned corporation has caused this Application for Registration of Name to be signed by a duly authorized officer thereof this day of , . Name of Corporation Signature Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB: 15-4131/6131 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 $70 made payable to the Department of State. B. The following, in addition to the filing fee, shall accompany the initial filing of this form: any necessary copies of form DSCB:17.2.3 (Consent to Appropriation of Name). C. This registration is effective for all or part of the calendar year for which it is filed. This filing must be renewed annually between October 1 and December 31 for the following calendar year. D. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com