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 54 Pa.C.S. § 502 (b) and (d) (relating to certain additions to register), the undersigned domestic unincorporated association, desiring to register with the Department of State the name under which it is doing business or operating, hereby states that: 1. The name to be registered is: ________________________________________________________________ 2. The address of the association is: ________________________________________________________________________________________________ Number and street City State Zip County 3. The length of time, if any, during which the name has been used by the applicant is: ____________________ IN TESTIMONY WHEREOF, the undersigned domestic unincorporated association has caused this Application for Registration of Unincorporated Association Name to be signed by a duly authorized officer this day of , 20 . ___________________________________________________ Name of Domestic Unincorporated Association ___________________________________________________ Signature ___________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:54-502­Instructions 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 domestic unincorporated association seeking to register an association name for a period of up to one year may file this form. This form is only to be used when the association is not otherwise required to be formed or organized by another type of filing. This registration will NOT formally incorporate, organize or form an association. See the Department's Registration Forms page for necessary forms. This form also will NOT register a d/b/a or fictitious name. Use DSCB:54311 (Registration of Fictitious Name). 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. Applicable Law For registration of name of unincorporated association, 54 Pa.C.S. § 502; for names, in general, 15 Pa.C.S. §§ 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. A name registered using this form may NOT use certain designators indicating it is incorporated or has limited liability (e.g. Inc., LLC, Limited, etc.) 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). (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. Give the exact name of the association. This should include the exact spelling and punctuation. This field is required. 2. The street and mailing address of the association's principal office. This address should be located in this Commonwealth. Post office boxes are not acceptable for any address. 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. This field is required. 3. The length of time which the registrant has used the name. An exact date is preferred but not required. Signature and Verification An authorized representative of the domestic association must sign this form. Signing a document delivered to the Department for filing is an affirmation under the penalties provided in 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) that the facts stated in the document are true in all material respects. This field is required. American