Form Il486-0513 - Application For A Medical Or Professional Corporation Registration Page 2
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1
2FOR OFFICIAL USE ONLY
APPLICATION FOR A MEDICAL OR
PROFESSIONAL CORPORATION REGISTRATION
IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure
under 805 ILCS 10/1 et. seq. or 805 ILCS 15/1 et. seq. (Illinois Compiled Statutes). Disclosure
of this information is VOLUNTARY. However, failure to comply may result in this form not
being processed.
NOTE: A separate application must be completed for each address listed in the purpose clause
of the Articles of Incorporation.
1. NAME OF CORPORATION (exactly as it appears on the Articles of Inc.)
2. TYPE OF REGISTRATION
3. FEIN NUMBER
Medical Corporation
Professional Service Corporation
4. OFFICE ADDRESS (Street Address, City, State, ZIP Code)
5. E-MAIL ADDRESS (REQUIRED)
6. DATE CORPORATION
FORMED
7. OFFICE TELEPHONE NUMBER
8. IDENTIFICATION OF SHAREHOLDERS, DIRECTORS, OFFICERS, AGENTS, AND EMPLOYEES OTHER THAN ANCILLARY PERSONNEL
NAME
ADDRESS (City, State, ZIP Code)
ILLINOIS LICENSE NUMBER
9. IF AN ATTORNEY LICENSED TO PRACTICE LAW IN ILLINOIS IS ACTING AS INITIAL INCORPORATOR ON BEHALF OF THE CORPORATION,
PROVIDE THE ATTORNEY'S NAME, BUSINESS ADDRESS AND TELEPHONE NUMBER.
ATTORNEY NAME
BUSINESS ADDRESS
TELEPHONE NUMBER
10. The corporation named in this application is using an assumed name. (An assumed name for a Medical Corpora-
Yes No
tion is any name that does not consist of the surname of any present or former shareholder. An assumed name for
a Professional Service Corporation is any name that does not consist of the full or last name of one or more of its
shareholders.)
Yes No
11. The assumed name and the name of the corporation's shareholders have been fi led with the Recorder if for a Medi-
cal Corporation or with the County Clerk if for a Professional Service Corporation in the County in which the principal
N/A
offi ce is located.
The name of the County is: _____________________________________________________________
12. The Articles of Incorporation have been fi led with the Illinois Secretary of State and a copy of the complete
Yes No
fi led Articles is attached.
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in
connection therewith, and to the best of my knowledge they are true, correct and complete.
Signature of Applicant
Date
I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. My signature above authorizes the Department of Financial
and Professional Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this
will be done only if the amount submitted is greater than the required fee hereunder, but in no event shall such reduction
be made in an amount greater than $50.
IL486-0513
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Parent category: Financial