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State Form 10555 - Application For Registration For An Accounting Professional Corporation

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APPLICATION FOR REGISTRATION FOR AN

INDIANA BOARD OF ACCOUNTANCY

PROFESSIONAL LICENSING AGENCY

ACCOUNTING PROFESSIONAL CORPORATION

402 West Washington Street, Room W072

State Form 10555 (R12 / 12-14)

Indianapolis, Indiana 46204

Approved by State Board of Accounts, 2013

Telephone: (317) 234-8800

E-mail: pla14@pla.in.gov

Professional accounting corporations may be organized for the practice of public accounting upon compliance with the Professional Corporation Act of 1983,

IC 23-1.5 and IC 23-1.5-2-3(a)(1).

Notification shall be given to the Secretary of State's Office and the Indiana Board of Accountancy within thirty (30) days after a change of business address

of the professional corporation and the admission or withdrawal of a shareholder, giving the names and addresses submitted to the Secretary of State's

Office and the Board of Accountancy. Pursuant to IC 25-2.1-5, a professional corporation must also obtain a permit to practice accountancy as a firm.

* Your Federal Identification number is requested by this agency in accordance with Indiana Code and it is mandatory that it be given. Numbers are made

available to the Department of Revenue.

FOR OFFICE USE ONLY

Application fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE

Firm license number

Date (month, day, year)

Federal Identification number *

The proposed Corporation known as _______________________________________________________________________________ is engaged in the

practice of public accountancy in this state and hereby makes application for registration pursuant to the Professional Corporation Act of 1983, IC 23-1.5.

The principal office of the corporation is:

Name of corporation

Address (number and street, city, state, and ZIP code)

Telephone number

E-mail address

(

)

List the names and addresses of all shareholders. State the type of license held, state of licensure, and registration number. At least one (1) shareholder

must be licensed in Indiana. Attach an additional 8 1/2 x 11 “ sheet if necessary. Please write N/A if not applicable.

NAME AND ADDRESS

TYPE OF LICENSE HELD STATE OF LICENSURE

REGISTRATION NUMBER

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