PENNSYLVANIA DEPARTMENT OF STATE 
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS 
                        
  Docketing Statement – New Entity 
                                                                         *134A*
                        DSCB:15-134A                                             
                            (rev. 7/2015)                                134A 
  
1. Entity Name: 
 
In the case of a foreign association which must use an alternate name to register to do business in Pennsylvania, the 
alternate name should be given. 
 
2. Tax Responsible Party 
 
Name of individual responsible for initial tax reports: ______________________________________________________ 
 
Mailing address of individual responsible for initial tax reports: 
 
__________________________________________________________________________________________________ 
 Number and street                               City                         State               Zip                   County 
 
3. Description of Business Activity:  
 
__________________________________________________________________________________________________