Domestic Professional Corporation Annual Report - Hawaiidepartment Of Commerce
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1STATE OF HAWAII
DOMESTIC PROFESSIONAL CORPORATION
RETURN ORIGINAL BY
PENALTY FOR LATE FILING
FILING FEE: $ 15.00
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
BUSINESS REGISTRATION DIVISION
H
Clear Form
335 Merchant Street
Mailing Address: Annual Filing, P.O. Box 113600, Honolulu, HI. 96811
DOMESTIC PROFESSIONAL CORPORATION ANNUAL REPORT AS OF
CORPORATE NAME AND MAILING ADDRESS:
If the above mailing address has changed, line out and print change to the right.
If address of principal office differs from the above mailing address, state the address of principal office. Include City, State, and Zip
Code: ________________________________________________________________________________________________
1.
TOTAL NUMBER OF SHARES ISSUED
AUTHORIZED SHARES
(To correct, line out and print the correction to the right.)
CLASS
NUMBER
CLASS
NUMBER
2. NATURE OF BUSINESS:
(To correct, line out and print corrections below. If inactive during the period, state INACTIVE.)
3. Street address of the registered office in Hawaii and the name of the registered agent at that address. (If any change, line out and print
change to the right. See reverse for instructions.) After any changes made, the streeet addresses of its registered office and agent
shall be identical.
4. OFFICERS/DIRECTORS: List all officers and directors. At least one director must be a resident of Hawaii.
(To correct, line out and print corrections on the right. See reverse instructions.)
OFFICE HELD/
DIRECTOR CODE
NAME IN FULL
ADDRESS (INCLUDE CITY, STATE & ZIP CODE)
NO CHANGES: Do not check this box if changes have been made above. (Checking this box means there are no
changes reported. The Department will not be held responsible for any changes made to this report.)
CERTIFICATION
I certify under the penalties of Section 414-20, Hawaii Revised Statutes, that I have read the above statements, that all of the
shareholders, not less than one-half of the directors other than the secretary and treasurer of this professional corporation are
qualified (licensed) persons, the information is true and correct, and I am authorized to sign this report.
DATE:
Print Name
Signature of authorized officer, attorney-in-fact
for an officer, or receiver or trustee
B17
(if the corporation is in the hands of a receiver or trustee)
FILE NO.
B22
Rev. 2/2005
File this Original
(SEE REVERSE SIDE FOR INSTRUCTIONS)
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