Form C017.001 Application For Officer/director/shareholder Change Form 2010 Page 3
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1
2
3Directors continued
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 director
Address change
Add as director
Name change
Remove director
Name change
Remove director
5.
SHAREHOLDER CHANGE –
FOR SHAREHOLDERS CURRENTLY SHOWN IN A.C.C. RECORDS – list the name
of each shareholder being changed as it is currently shown in A.C.C. records, and below that provide the new
name, if any, for that shareholder, then check a box to indicate the change being made for that shareholder. FOR
NEW SHAREHOLDERS – list the name in the NEW Name blank 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
Name change
Add as shareholder
Name change
Add as shareholder
Remove shareholder
Remove shareholder
Name currently shown in ACC records
Name currently shown in ACC records
NEW Name
NEW Name
Name change
Add as shareholder
Name change
Add as shareholder
Remove shareholder
Remove shareholder
SIGNATURE –
see Instructions C017i
for who is authorized to make changes:
By checking the box marked "I accept" below, I acknowledge under penalty of perjury that this document
together with any attachments is submitted in compliance with Arizona law.
I ACCEPT
Signature
Printed Name
Date
REQUIRED – check only one:
I am the Chairman of the Board
I am a duly-authorized Officer of
I am a duly authorized
of Directors of the corporation
the corporation filing this document.
bankruptcy trustee, receiver,
filing this document.
or other court-appointed
fiduciary for the corporation
filing this document.
Filing Fee: None (regular processing)
Mail:
Arizona Corporation Commission - Corporate Filings Section
Expedited processing – add $35.00 to filing fee.
1300 W. Washington St., Phoenix, Arizona 85007
All fees are nonrefundable - see Instructions.
Fax:
602-542-4100
Please be advised that A.C.C. forms reflect only the minimum provisions required by statute. You should seek private legal counsel for those matters that may pertain
to the individual needs of your business.
All documents filed with the Arizona Corporation Commission are public record and are open for public inspection.
If you have questions after reading the Instructions, please call 602-542-3026 or (within Arizona only) 800-345-5819.
C017.001
Arizona Corporation Commission – Corporations Division
Rev: 2010
Page 3 of 3
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