State Form 10555 - Application For Registration Of A Professional Corporation - 2000

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INDIANA BOARD OF ACCOUNTANCY

APPLICATION FOR REGISTRATION OF

302 W. Washington Street, Room E034

A PROFESSIONAL CORPORATION

Indianapolis, IN 46204

State Form 10555 (R6 / 6-00)

Approved by State Board of Accounts, 2000

FEE: $25.00

INSTRUCTIONS TO APPLICANT: Professional accounting corporations may be organized for the practice of public accounting upon compliance with the

Professional Corporation Act of 1983, IC 23-1.5 administered by the Office of the Secretary of State of Indiana, State

House, Indianapolis, Indiana.

Notification shall be given to the Secretary of State's Office and the Indiana Board of Accountancy within thirty (30) days

after a change of business address of the Corporation and the admission to or withdrawal of a shareholder. Also a certified

copy of all amendments to the articles of incorporation must be submitted to the Secretary of State's Office and the Board

of Accountancy.

One shareholder shall execute affidavit of shareholder on page two of this application.

* Federal ID number or Social Security number is requested by this agency in accordance with IC 4-1-8-1 and is mandatory that it be given. Numbers

are made available to the Department of Revenue.

Federal ID number *

Date

Social Security number *

The Corporation known as

is engaged in the practice of public accountancy in this state and hereby makes application for registration pursuant to The Professional Corporation Act of

1983, IC 23-1.5.

1 .

The name and address of the principal office of the corporation within the state of Indiana is

Telephone number:

Other offices located within the state of Indiana are:

2 .

Name of office

CPA of state

Office address

Indiana PA-AP

IN CPA cert.

manager