PC
Filing Fee: $125.00
Late Fee: $25.00
The Commonwealth of Massachusetts
FPC
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Annual Report for Professional and
FORM MUST BE TYPED
FORM MUST BE TYPED
Foreign Professional Corporations
(General Laws Chapter 156A, Section 18 and Chapter 156D, Section 16.22)
(1) Exact name of the corporation: _______________________________________________________________________________________
(2) Jurisdiction of incorporation: _________________________________________________________________________________________
(3) Street address of the corporation’s registered offi ce in the commonwealth:
_______________________________________________________________________________________________________________
(number, street, city or town, state, zip code)
(4) Name of the registered agent at the registered offi ce: _______________________________________________________________________
(5) Street address of the corporation’s principal offi ce:
_______________________________________________________________________________________________________________
(number, street, city or town, state, zip code)
(6) Provide the names and addresses of the corporation’s board of directors, shareholders, and its president, treasurer, secretary, and if diff erent, its
chief executive offi cer and chief fi nancial offi cer.
NAME
ADDRESS
President: ________________________________________________________________________________________________________
Treasurer: ________________________________________________________________________________________________________
Secretary: ________________________________________________________________________________________________________
Chief Executive Offi cer: _____________________________________________________________________________________________
Chief Financial Offi cer: _____________________________________________________________________________________________
Directors: _______________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Shareholders (with residential address): _________________________________________________________________________________
(7) Briefl y describe the business of the corporation:
_______________________________________________________________________________________________________________
(8-9) Capital stock of each class and series:
CLASS OF STOCK
TOTAL AUTHORIZED BY ARTICLES OF ORGANIZA-
TOTAL ISSUED AND OUTSTANDING
TION OR AMENDMENTS
Number of Shares
Number of Shares
COMMON
PREFERRED
(10) Check if the stock of the corporation is publicly traded. ®
(11) Report is fi led for fi scal year ending: ________________________ / ________________________ /_______________________________
(month)
(day)
(year)
It is hereby certifi ed, pursuant to G.L. Chapter 156A, Section 18, that the shareholders, and all the partners of a general partnership which is a share-
holder of the corporation are duly licensed to render one or more professional services for which the corporation was organized, or are professional
corporations authorized to render such professional services, and that a copy of this report is being sent to the appropriate regulatory board.
Signed by: __________________________________________________________________________________________________________
® Chairman of the board of directors
® President
® Other offi cer
® Court appointed fi duciary
on this ____________________________________ day of _______________________________________________
day of _______________________________________________
day of
, _________________ .
c156as18c156ds1622 01/13/05