Form 080107 - Application For Incorporation Of A Nevada Ic-Disc Page 2
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2IC-DISC INFORMATION
1) Proposed name of IC-DISC: ___________________________________________________________________
(Must include a corporate ending, i.e. Incorporated, Corporation, Company or an abbreviation, i.e. Inc.)
List two (2) alternatives: ______________________________________________________________________
______________________________________________________________________
2) Mailing address of IC-DISC: 1802 North Carson Street, Suite 212, Carson City, NV 89701
3)
Telephone: 800-894-8366
Fax: 888-894-8366
4) Authorized shares (common, $1.00 par value per share): q 2,500
q Other: __________________________
(Select a number that is evenly divisible by the number of proposed shareholders. Must be at least 2,500
.)
5) Shareholder:___________________________________________________ U.S. SS#: ___________________
Permanent Residence: _______________________________________________________ % of Interest: ____
Shareholder:___________________________________________________ U.S. SS#: ___________________
Permanent Residence: _______________________________________________________ % of Interest: ____
q Traditional IRA
q Roth IRA
Should it be IRA-owned, include:
Beneficiary/Owner: ________________________________________________ Telephone: ________________
Custodian Contact: _______________________________________________ Telephone: ________________
(Use a separate sheet for additional shareholder information.)
6) Total paid-in capital of the IC-DISC: q $2,500
q Other: $__________________________
7) Name(s) of director(s) of the IC-DISC: ___________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(At least one director is required.)
8)
Name(s), titles and social security number(s) of officers of the IC-DISC:
President: ________________________________________________ U.S. SS#: _______________________
Secretary: ________________________________________________ U.S. SS#: _______________________
Treasurer: ________________________________________________ U.S. SS#: _______________________
(Should have at least a President, Secretary and Treasurer, all of whom may be the same person.)
INFORMATION FOR U.S. TAX IDENTIFICATION NUMBER OF IC-DISC
(Form SS-4)
1) Date of fiscal year end (must be same as shareholders):
q December 31
q Other, please specify: _____________________________________________________
2) If a Buy/Sell IC-DISC, to whom does it sell its products/services: q Wholesale (businesses)
q Retail (public)
q Other, please specify: ______________________________________________________
An authorized signature provides Export Assist with consent to proceed with your incorporation request for a
Managed IC-DISC. Any changes to your corporate legal structure (i.e., change from C to S corporation) must be
reported to Export Assist, Inc. prior to change due to potential tax ramifications.
Authorized Signature: ________________________________________________ Date: ____________________
Name (please print): __________________________________________________ Title: ____________________
080107
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