PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Return document by email to: _________________________________ Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/. Fee: $250 I qualify for a veteran/reservist-owned small business fee exemption (see instructions) In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 412 (relating to foreign registration statement), the undersigned foreign association hereby states that: 1. The type of association is (check only one): Business Corporation Nonprofit Corporation Limited Liability Company Limited Partnership Limited Liability (General) Partnership Limited Liability Limited Partnership Business Trust Professional Association 2. The full and proper name of the foreign association as registered in its jurisdiction of formation is: 2A. If the name in 2 does not contain a required designator or if the name in 2 is not available for use in the Commonwealth, the alternate name under which the association is registering in this Commonwealth is: 3. The jurisdiction of formation is: _____________________________________________________________________ 4. The street and mailing address of the association's principal office. ____________________________________________________________________________________________________________ Number and street City State Zip 4A. The street and mailing address of the office, if any, required to be maintained by the law of the association's jurisdiction of formation in that jurisdiction: ____________________________________________________________________________________________________________ Number and street City State Zip American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-412 - 2 5. The (a) address of the association's proposed registered office in this Commonwealth or (b) name of its Commercial Registered Office Provider and the county of venue is: Complete part (a) OR (b) ­ not both: (a) ________________________________________________________________________________________________________ Number and street City State Zip County OR (b) c/o: _____________________________________________________________________________________________________ Name of Commercial Registered Office Provider County 6. Check one of the following: The association may not have series. The association may have one or more series. 7. Effective date of registration of foreign association (check, and if appropriate complete, one of the following): The Foreign Registration Statement shall be effective upon filing in the Department of State. The Foreign Registration Statement shall be effective on: _________________________ at __________________. Date (MM/DD/YYYY) Hour (if any) 8. To be completed by Limited Liability Companies only. Check, and if appropriate complete, one of the following: The association is a limited liability company which is not organized to render any of the below professional service(s). The association is a restricted professional limited liability company organized to render one or more of the following professional service(s): (If this box is checked, one or more of the fields below must be checked.) ___Chiropractic ___Optometry ___Psychology ___Dentistry ___Osteopathic medicine and surgery ___Veterinary medicine ___Law ___Podiatric medicine ___Medicine and surgery ___Public accounting IN TESTIMONY WHEREOF, the undersigned association has caused this Foreign Registration Statement to be signed by a duly authorized representative thereof this ______________ day of ____________________________, 20_________. ______________________________________ Name of Association ___________________________________________________ Signature ___________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-412­Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Website: www.dos.pa.gov/corps General Information Typewritten is preferred. If handwritten, the form must be legible and completed in black or blue-black ink in order to permit reproduction. The nonrefundable filing fee for this form is $250. Checks should be made payable to the Department of State. Checks must contain a commercially pre-printed name and address. Filers requesting a veteran/reservist-owned small business fee exemption should attach proof of the veteran's or reservist's status to the Foreign Registration Statement form when submitted. For more information on the fee exemption, see Fees and Payments. This form and all accompanying documents shall be mailed to the address stated above. A foreign corporation (both business and nonprofit corporation) is required by 15 Pa.C.S. § 4124 or by 15 Pa.C.S. § 6124 (relating to advertisement) to advertise its intention to register or its registration to do business in Pennsylvania. Proofs of publication of such advertising should not be submitted to, and will not be filed in, the Department, but should be filed with the minutes of the corporation. Who should file this form? Foreign filing associations are corporations for profit, corporations not-for-profit, limited partnerships, limited liability companies, professional associations and business or statutory trusts that were not created or formed under the laws of Pennsylvania. Foreign filing associations and foreign limited liability partnerships desiring to do business in this Commonwealth must register with the Department of State by filing this form. A foreign filing association or foreign limited liability partnership may not do business in this Commonwealth until it registers with the Department. See 15 Pa.C.S. § 403 for activities that do not constitute doing business in this Commonwealth. It is up to the association to determine whether its activities require it to register with the Department of State. Applicable Law For foreign associations, in general, 15 Pa.C.S. §§ 102; 401419; for registration statement, 15 Pa.C.S. § 412; for names, 15 Pa.C.S. § 414 and §§ 201-209. Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. Assocation Name Requirements Generally, the name of an association may not be the same as the name of another association which is