State Form 32662 - Application For Registration For Professional Corporation

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FOR OFFICE USE ONLY

APPLICATION FOR REGISTRATION FOR

CONTROL NUMBER

PROFESSIONAL CORPORATION

State Form 32662 (R3 / 7-99)

INDIANA STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS

AND BOARD OF REGISTRATION FOR LAND SURVEYORS

Approved by the State Board of Accounts 1991

Check one Corporation type:

Engineer

Date (month, day, year)

FEE:

$25.00

Land Surveyor

Engineer / Land Surveyor

Federal I.D. number

INSTRUCTIONS:

MAIL check or money order payable to: INDIANA PROFESSIONAL LICENSING AGENCY

Federal I.D. number is requested pursu-

302 W WASHINGTON ST RM E034

ant to IC 4-1-8.1, however it is not manda-

INDIANAPOLIS IN 46204

tory. Number will be given to the Depart-

ment of Revenue.

Professional Engineer and Land Surveyor Corporations may be organized for the practice of engineering and / or land surveying upon compliance with the

Professional Corporation Act of 1983, IC 23-1.5 administered by the office of the Secretary of State of Indiana, State House, Indianapolis, Indiana 46204.

Notification shall be given to the Secretary of State's Office and the Indiana Board of Registration for Professional Engineers within thirty (30) days after a

change of business address of the Corporation and the admission or withdrawal of a shareholder, giving the names and addresses of both the transferer and

transferee shareholders. Also, a certified copy af all amendments to the Articles of Incorporation must be submitted to the Secretary of State's Office and the

Board of Registration for Professional Engineers.

One shareholder shall execute affidavit of shareholder on the back of this application.

Gentlemen:

The Proposed Corporation known as ___________________________________________________________________________

is engaged in the practice of engineering 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 within the State of Indiana is:

Name

Address (street, city, state, ZIP code)

Telephone number

SHAREHOLDERS, DIRECTORS AND OFFICERS

List name, address and registration data of each shareholder, director and officer practicing or licensed in Indiana, and check appropriate box in last

column. Attach additional 8 1/2 x 11 sheet if necessary.

INDIANA LS

INDIANA PE

NAME AND ADDRESS

STATUS

REGISTRATION NO.

Shareholder

Director

Officer

Shareholder

Director

Officer