Application for Registration of Fictitious Name (Pennsylvania)
This form registers a fictitious name and the nature of the business in Pennsylvania. The form provided here is simply a sample of what the actual Form 311 looks like.
Application for Registration of Fictitious Name
54 Pa. C.S. § 311
Name _____________________________
Address ___________________________
City _______________________________
State ______________________
Zip Code __________________
Document will be returned to the name and address you enter
In compliance with the requirements of 54 Pa.C.S. § 311 (relating to registration), the undersigned entity(ies) desiring to register a fictitious name under 54 Pa.C.S. Ch. 3 (relating to fictitious names), hereby state(s) that:
1. The fictitious name is: ___________________________________
2. A brief statement of the character or nature of the business or other activity to be carried on under or through the fictitious name is: __________________________________
3. The address, including number and street, if any, of the principal place of business (P.O. Box alone is not acceptable):
Number and Street _____________________________
City ______________________________
State _____________________________
Zip ____________________
County _________________
4. The name and address, including number and street, if any, of each individual interested in the business is:
Name _________________________
Number and Street _____________________________
City ______________________________
State _____________________________
Zip ____________________
Name _________________________
Number and Street _____________________________
City ______________________________
State _____________________________
Zip ____________________
5. Each entity, other than an individual, interested in such business is (are):
_____________________ Name
_____________________ Form of Organization
_____________________ Organizing Jurisdiction
_____________________ Principal Office Address
_____________________ PA Registered Office, if any
_____________________ Name
_____________________ Form of Organization
_____________________ Organizing Jurisdiction
_____________________ Principal Office Address
_____________________ PA Registered Office, if any
6. The applicant is familiar with the provisions of 54 Pa.C.S. § 332 (relating to effect of registration) and understands that filing under the Fictitious Names Act does not create any exclusive or other right in the fictitious name.
7. Optional: The name(s) of the agent(s), if any, any one of whom is authorized to execute amendments to, withdrawals from or cancellation of this registration in behalf of all then existing parties to the registration, is (are): _________________________________
IN TESTIMONY WHEREOF, the undersigned have caused this Application for Registration of Fictitious Name to be executed this __________________ day of ____________________, _________.
Individual Signature ___________________________________________
Individual Signature ___________________________________________
Entry Name _____________________________________
Entry Name _____________________________________
Signature _____________________________________
Signature _____________________________________
Title __________________________________________
Title __________________________________________
-----------------------------
INSTRUCTIONS FOR FILLING OUT THIS FORM
-----------------------------
Department of State
Corporation Bureau
P.O. Box 8722
Harrisburg, PA 17105-8722
(717) 787-1057
Web site: www.dos.state.pa.us/corps
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. 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) Any necessary copies of form DSCB:17.2.3 (Consent to Appropriation of Name).
(2) Any necessary governmental approvals.
D. For general instructions relating to fictitious name registration see 19 Pa. Code Subch. 17C (relating to fictitious names). These instructions relate to such matters as voluntary and mandatory registration, general restrictions on name availability, use of corporate designators, agent for effecting amendments, etc., execution, official advertising when an individual is a party to the registration, and effect of registration and non-registration.
E. The name of a commercial registered office provider may not be used in Paragraph 3 in lieu of an address.
F. Insert in Paragraph 5 for each entity which is not an individual the following information: (i) the name of the entity and a statement of its form of organization, e.g., corporation, general partnership, limited partnership, business trust, (ii) the name of the jurisdiction under the laws of which it is organized, (iii) the address, including street and number, if any, of its principal office under the laws of its domiciliary jurisdiction and (iv) the address, including street and number, if any, of its registered office, if any, in this Commonwealth. If any of the entities has an association which has designated the name of a commercial registered office provider in lieu of a registered office address as permitted by 15 Pa.C.S. § 109, the name of the provider and the venue county should be inserted in the last column.
G. Every individual whose name appears in Paragraph 4 of the form must sign the form exactly as the name is set forth in Paragraph 4. The name of every other entity listed in Paragraph 5 shall be signed on its behalf by an officer, trustee or other authorized person. See 19 Pa. Code § 13.8(b) (relating to execution), which permits execution pursuant to power of attorney. A copy of the underlying power of attorney or other authorization should not be submitted to, and will not be received by or filed in, the Department.
H. An entity (which includes an individual) that registers a fictitious name is required by 54 Pa.C.S. § 311(g) to advertise its intention to file or the filing of an application for registration of fictitious name. Proofs of publication of such advertising should not be submitted to the Department, and will not be received by or filed in the Department, but should be kept with the permanent records of the business.
I. This form and all accompanying documents shall be mailed to the address stated above.