Fictitious Name Registration – Esquire Assist, Ltd.

Step 1 of 4 – Client Information

25%

Are you and existing client of Esquire Assist?(Required)

Yes

Return Document by

Mail

Your Name and Firm Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State 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

Number and Street, City, State, Zip

Each entity, other than an individual, interested in such business is (are)

Number of Entities(Required)

Name(Required)

Form of Organization(Required)

Organizing Jurisdiction(Required)

Principal Office Address(Required)

PA Registered Office(Required)

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.

(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

Entity Name

Signature

By typing your name here you understand that the document will be digitally signed by you as if you manually signed a form.

Title

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.