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Fictitious Name Registration
Step
1
of
4
– Client Information
25%
Are you and existing client of Esquire Assist?
(Required)
Yes
No
Return Document by
Email
Mail
Your Name and Firm Name
(Required)
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
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Armed Forces Americas
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Zip Code
I qualify for a veteran/reservist-owned small business fee exemption
Yes
Attach a photo of DD214 or a Military ID Card
(Required)
Max. file size: 500 MB.
The fictitious name is
(Required)
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
(Required)
The address, including number and street, if any, of the principal place of business
(Required)
Number and Street, City, State, Zip (post office box alone is not acceptable)
The county of the principal place of business
(Required)
The name and address, including number and street, if any, of each individual interested in the business is:
Number of Individuals
Name
Add
Remove
Number and Street, City, State, Zip
Add
Remove
Each entity, other than an individual, interested in such business is (are)
Number of Entities
(Required)
Name
(Required)
Add
Remove
Form of Organization
(Required)
Add
Remove
Organizing Jurisdiction
(Required)
Add
Remove
Principal Office Address
(Required)
Add
Remove
PA Registered Office
(Required)
Add
Remove
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.
(Required)
I agree.
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.
(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
Date
MM slash DD slash YYYY
Individual Signature
Add
Remove
Entity Name
Add
Remove
Signature
Add
Remove
By typing your name here you understand that the document will be digitally signed by you as if you manually signed a form.
Title
Add
Remove
How would you like this form submitted?
(Required)
Routine
Expedited
Expedited Options
(Required)
$100 (8-10 AM – Back by 5 PM)
$300 (8 AM – 2 PM – Back within 3 hours)
$1,000 (8 AM to 4 PM – Back within 1 hour /pre authorization required)
Call us with any questions about these options as our cutoff times are different from the State.
Please include any special instructions
Name
This field is for validation purposes and should be left unchanged.
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