Domestic Profit Corporation Annual Report Form - 2004
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1STATE OF HAWAII
DOMESTIC PROFIT CORPORATION
RETURN ORIGINAL BY
FILING FEE: $ 25.00
PENALTY FOR LATE FILING
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
BUSINESS REGISTRATION DIVISION
H
335 Merchant Street
Clear Form
Mailing Address: Annual Filing, P.O. Box 113600, Honolulu, HI. 96811
DOMESTIC PROFIT 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. AUTHORIZED SHARES
TOTAL NUMBER OF SHARES ISSUED
(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 on the right. See reverse for instructions.)
4.
List all officers and directors. (To correct, line out and print corrections to the right. See reverse for instructions.)
OFFICERS/DIRECTORS:
OFFICE HELD/
ADDRESS (INCLUDE CITY, STATE & ZIP CODE)
DIRECTOR CODE
NAME IN FULL
Do not check this box if changes have been made above. (Checking this box means there are no changes
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, the
information is true and correct, and I am authorized to sign this report.
DATE:
Signature of authorized officer, attorney-in-fact
Print Name
for an officer, or receiver or trustee
(if the corporation is in the hands of a receiver or trustee)
FILE NO.
B17
Rev. 3/2004
B22
File this Original
(SEE REVERSE SIDE FOR INSTRUCTIONS)
Page
1 of 2
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