Form Cfd-03 - Health Spa Consumer Protection Act printable pdf download

Form Cfd-03 - Health Spa Consumer Protection Act

Arkansas Secre t a ry of State

Charlie Daniels

State Capitol • Little Rock, Arkansas 72201-1094

501-682-3409 •

I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class

C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days.

NOTE: Subsequent annual reports may be filed within thirty (30) days of the anniversary date of this filing.

Health Spa Consumer Protection Act

(Act 264 of 1989)

Annual Registration Statement

Date:

(Please Submit in Duplicate)

Name of Health Spa:

Street Address:

The name and addresses of all officers, directors and stockholders of the Health Spa as follows:

Name

Position Held

Address

(Attach separate list if necessary)

Name of Health Spa's parent corporation, if applicable:

Street Address:

The names and street addresses of all officers, directors and stockholders of the Health Spa's parent corporation are as follows:

Name

Position Held

Address

(Attach separate list if necessary)

The types of facilities available are as follows:

Name, street address and telephone number of a contact person responsible for filing annual registration:

NAME

(Signature of Contract Person)

STREET ADDRESS

(Telephone Number)

ADDRESS:

City

State

ZIP

CFD-03 Rev. 4/06

Form Cfd-03 - Health Spa Consumer Protection Act