Read all instructions prior to completing. This form may be submitted online at
Fee: $70 I qualify for a veteran/reservist-owned small business fee exemption (see instructions)
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:
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
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:
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
Return document by mail to:
City State Zip Code
Return document by email to: _________________________________
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
IN TESTIMONY WHEREOF, the undersigned have caused this Application for Registration of Fictitious
Name to be executed this
day of ,
__________________________________________ __
Individual Signature Individual Signature
__________________________________________ __________________________________________
Individual Signature Individual Signature
__________________________________________ __________________________________________
Entity Name Entity Name
__________________________________________ __________________________________________
Signature Signature
__________________________________________ __________________________________________
Title Title
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):
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.
Pennsylvania Department of State
Bureau of Corporations and Charitable Organizations
P.O. Box 8722
Harrisburg, PA 17105-8722
(717) 787-1057
Instructions for Completion of Form:
A. Typewritten is preferred. If handwritten, the form shall be legible and completed in black or blue-black ink in order to
permit reproduction. The nonrefundable filing fee for this form is $70 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 Registration of Fictitious Name
form when submitted. For more information on the fee exemption, see Fees and Payments
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.
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
C. 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.
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.