Notice is hereby given pursuant to the provisions of Act 1982-295 of December 16, 1982, of the filing in the Office of the Secretary of the Commonwealth of Pennsylvania, at Harrisburg, on the*

Day of*

Year*

A Certificate for the conduct of a business in*

County, Pennsylvania, under the assumed or fictitious name, style or designation of *

With its principal place of business at: *

The name(s) and address(es) of all person(s) owning or interested in said business is(are):*

Attorney:

Address attorney:

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Name:*

Address: *

Phone: *

Cost:*

Form of Payment:*

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Submitters Name *

First

Last

Submitters Address*

Street Address City State / Province / Region Postal / Zip Code

Submitters Phone:

Submitters Email*

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