This government document is issued by Drug and Alcohol Programs for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:ug3qpcrqbm4&q=https://www.ddap.pa.gov/Agency%2520Forms/Licensure/Ownership%2520and%2520Business%2520Management%2520Form.docx&sa=U&ved=2ahUKEwjUouahl_GFAxXlg_0HHekfCNQ4ChAWegQICBAB&usg=AOvVaw1KUEa3tZbpkDw9RseKyy8f