Form C017.001 Application For Officer/director/shareholder Change Form 2010
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DO NOT WRITE ABOVE THIS LINE; RESERVED FOR ACC USE ONLY.
OFFICER/DIRECTOR/SHAREHOLDER CHANGE
Read the Instructions
C017i
1.
ENTITY NAME – give the exact name of the corporation as currently shown in A.C.C. records:
_________________________________________________________________________________________________
A.C.C. FILE NUMBER: ___________________________________________________________
2.
Find A.C.C. file number on the upper corner of filed documents OR on our website at:
CHECK THE BOX NEXT TO EACH CHANGE BEING MADE AND
COMPLETE THE REQUESTED INFORMATION FOR THAT CHANGE.
3.
OFFICER CHANGE –
FOR OFFICERS CURRENTLY SHOWN IN A.C.C. RECORDS - list the name of each officer
being changed as it is currently shown in A.C.C. records, and below that provide any new information for that
officer (new name and/or address), then check all boxes that apply to indicate the change being made for that
officer. FOR NEW OFFICERS – list the name in the NEW Name blank, list the address, and check the appropriate
box.
If more space is needed, use another Officer/Director/Shareholder Change form.
Name currently shown in ACC records
Name currently shown in ACC records
NEW Name
NEW Name
Address 1
Address 1
Address 2 (optional)
Address 2 (optional)
City
State or
Zip
City
State or
Zip
Province
Province
Country
Country
Date taking office (optional)
Officer title
Date taking office (optional))
Officer title
Address change
Add as officer
Address change
Add as officer
Name change
Remove officer
Name change
Remove officer
Name currently shown in ACC records
Name currently shown in ACC records
NEW Name
NEW Name
Address 1
Address 1
Address 2 (optional)
Address 2 (optional)
City
State or
Zip
City
State or
Zip
Province
Province
Country
Country
Date taking office (optional)
Officer title
Date taking office (optional)
Officer title
Address change
Add as officer
Address change
Add as officer
Name change
Remove officer
Name change
Remove officer
C017.001
Arizona Corporation Commission – Corporations Division
Rev: 2010
Page 1 of 3
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