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 registration expires on December 31 of each year and must be renewed annually between October 1 and December 31. Fee: $70 Check one: Initial registration Renewal of registration In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 209 (relating to registration of name of nonregistered foreign association), 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 Other _________________ 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 principal office address of the nonregistered foreign association is: ___________________________________________________________________________________________________________ Number and street City State Zip IN TESTIMONY WHEREOF, the undersigned nonregistered foreign association has caused this Application for Registration of Name to be signed by a duly authorized officer thereof this _______________ day of _____________________________, 20______. ___________________________________________________ Name of Nonregistered Foreign Association ___________________________________________________ Signature ___________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-209­Instructions 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 $70. Checks should be made payable to the Department of State. Checks must contain a commercially pre-printed name and address. This form and all accompanying documents, including any necessary governmental approvals, shall be mailed to the address stated above. Who should file this form? Any nonregistered foreign association seeking to register an association name for a period of up to one year may file this form. Available names will be registered though December 31 of the year in which the registration is filed. Registrations may be renewed annually between October 1 and December 31 for the following calendar year. Initial registrations filed between October 1 and December 31 will expire on December 31 of the following calendar year. A foreign association whose name registration is effective may register as a foreign association under the registered name or consent to the use of that name by another association. Applicable Law For registration of name of nonqualified foreign association, 15 Pa.C.S. § 209; for names, in general, 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. Association Name Requirements Generally, the name of an association may not be the same as the name of another association which is already on the records of the Department of State. Depending on the type of association, certain designators must be used in the association name. The minimum requirements for association names can be found at 15 Pa.C.S. §§ 201-209. Provisions relating to foreign association names are at 15 Pa.C.S. § 206 and § 414. Restricted word and/or approvals: Association names may not contain words, phrases or abbreviations prohibited or restricted by statute or regulation, unless in compliance with the restriction, generally with the consent or approval of a government agency, board or commission. These may include certain professional and occupational boards or commissions of the Bureau of Professional and Occupational Affairs, the Department of Education, the Department of Banking and Securities, the Insurance Department or the Public Utility Commission. There are also words and abbreviations that may be restricted, prohibited, or may be permitted in certain instances as provided in various federal statutes, Attorney General opinions and Bureau regulations. Attachments The following, in addition to the filing fee, shall accompany this form: (1) Any necessary copies of form DSCB:19-17.2 (Consent to Appropriation of Name). If Consent cannot be obtained, the association may adopt, for the purpose of doing business in this Commonwealth, an alternate name as indicated in Instruction 2A. (2) Any necessary governmental approvals. Form Instructions Enter the name and mailing address to which any correspondence regarding this filing should be sent. This field must be completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become part of the filed document and therefore public record. Indicate whether the application is an initial registration or whether the application is being renewed. Renewals must be submitted for filing between October 1 and December 31 for the following calendar year. 1. Select the type of association. Only one option may be selected. This field is required. 2. Give the exact name of the nonregistered foreign association in its jurisdiction of formation. This should include the exact spelling, punctuation and any identifier such as "Inc.," "LLC" or "Limited." Jurisdiction of Formation means the state or country of incorporation or domestic registration. For the purposes of this form, the jurisdiction of formation may not be Pennsylvania. This field is required. 2A. Alternate name: A foreign association must register under its proper name under the laws of its j