State Form 32662 - Application For Registration For Professional Corporation Page 2
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1
2SHAREHOLDERS, DIRECTORS AND OFFICERS (continued)
INDIANA LS
INDIANA PE
NAME AND ADDRESS
STATUS
REGISTRATION NO.
REGISTRATION NO.
Shareholder
Director
Officer
Shareholder
Director
Officer
Shareholder
Director
Officer
Shareholder
Director
Officer
Shareholder
Director
Officer
AFFIDAVIT OF SHAREHOLDER
A CORPORATION OF PROFESSIONAL ENGINEERS OR REGISTERED LAND SURVEYORS AND/OR
PROFESSIONAL ENGINEERS AND REGISTERED LAND SURVEYORS
STATE OF
}
SS:
COUNTY OF
_______________________________________________________________ being duly sworn, deposes and says that he/she
is a Registered Engineer or Land Surveyor of the State of Indiana, his/her office and principal place of business being located at
__________________________________________________________________, Indiana. That he/she is a shareholder of the
Corporation known as ______________________________________________________________, that all statements made in
this application regarding the said Corporation are true; that said Corporation has complied with all provisions of corporation laws
of this State applicable thereto; that each shareholder of said Corporation is a Registered Engineer or Land Surveyor in good
standing of the State of Indiana; that each officer is a Registered Engineer or Land Surveyor of Indiana in good standing; and
each director is a qualified person as defined by IC 25-31-1-18.
Subscribed and sworn to before me this ____________ day of _______________________________________, __________.
Signature of Applicant
Signature of Notary Public
Printed or Typed Name of Applicant
Printed or Typed Name of Notary Public
Date Subscribed and Sworn To (Notary Public)
Date Commission Expires
County of Residence
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