Form 17-2718 - Professional Corporate Annual Report

Form 17-2718 - Professional Corporate Annual Report - 2000 Page 2

Except for a professional certified public accountant corporation, only a qualified person may be a shareholder of

a professional corporation (K.S.A. 17-2712). No person may be a director or officer, other than the secretary, of

a professional corporation unless that person is a shareholder (K.S.A. 17-2713).

(a) Is each officer, director and shareholder listed above a qualified person as defined by law (K.S.A. 17-2707)?

YES ___

NO ___

(b) If NO, list those persons who are not qualified as defined by law.

_____________________________________________________

qualified person. ________________________________________________

7. F.E.I.N. ________________________________

8. Telephone No. ______________________________

Federal Employer Identification Number

Shares issued (Common or Preferred)

Total Stock Paid Up

10. Indicate the types of licensed professionals that practice through the corporation:

_____ Architect

_____ Chiropractor

_____ Certified Public Accountant _____ Registered professional nurse

_____ Veterinarian

_____ Podiatrist

_____ Pharmacist

_____ Licensed clinical psychologist

_____ Attorney-at-law

_____ Land surveyor _____ Optometrist

_____ Specialist in clinical social work

_____ Dentist

_____ Engineer

_____ Landscape architect

_____ Registered physical therapist

_____ Osteopathic physician or surgeon

_____ Physician, surgeon or doctor of medicine

I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.

Executed on the ________ of ___________, _____________.

Day

Month

Year

Name of signer (printed or typed)

Authorized Signature

Title/Position

Rev. 10/00 mb

K.S.A. 17-2718

Form 17-2718 - Professional Corporate Annual Report - 2000 Page 2