Form Pa 50 - Professional Corporation Annual Report Page 2
ADVERTISEMENT
1
28. Shareholders (entity must have at least one shareholder):
___________________________________________________________________________________________
Name
Address
City
State
Zip
__________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
9. 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). (Exception: A certified
public accountant professional corporation.)
(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:
____________________________________________________________________________________
(c) If any shares are owned by a nonqualified person, give the dates on which any shares were owned by a
nonqualified person: ____________________________________________________________________
10. Total amount of capital stock issued: __________________________________
11. Indicate the types of professionals who practice through the corporation:
___ Certified Public Accountant
___ Veterinarian
___ Real Estate Broker or Salesperson
___ Architect
___ Podiatrist
___ Clinical Professional Counselor
___ Attorney-at-Law
___ Pharmacist
___ Geologist
___ Chiropractor
___ Land Surveyor
___ Clinical Psychotherapist
___ Dentist
___ Licensed Psychologist
___ Clinical Marriage and
___ Engineer
___ Specialist in Clinical Social Work
Family Therapist
___ Optometrist
___ Licensed Physical Therapist
___ Licensed Physician Assistant
___ Osteopathic Physician or Surgeon
___ Landscape Architect
___ Licensed Occupational Therapist
___ Physician, Surgeon or Doctor
___ Registered Professional Nurse
of Medicine
12. I declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and correct and that I
have remitted the required fee.
Executed on the ________ of ________________, _____________.
Day
Month
Year
Signature of authorized officer
Name of signer (printed or typed)
Title/Position
Phone number
K.S.A. 17-2718
Rev. 11/01/05 nr
2/3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal