Application For Certification And Registration Of A Professional Corporation With The North Carolina Medical Board (Page 2 of 4) in pdf

Application For Certification And Registration Of A Professional Corporation With The North Carolina Medical Board Page 2

NCMB Professional

Corporation/Limited Liability Company

Address Form

Professional

Corp./LLC Name:___________________________________________________

The information below is used for mailing Professional Corporation/LLC registration renewal notices and

other communications, as necessary, from the North Carolina Medical Board. Please remember to update

this information when there are any changes

(Street 1)____________________________________________________________

(Street 2)____________________________________________________________

(Street 3)____________________________________________________________

(City)____________________________________(State)_____________________

(Zip)_____________________________________ (County)___________________

(Phone)___________________________________(Fax)______________________

(Email)______________________________________________________________

•

New PCs or PLLCs: please mail, with your application for certification & registration packet.

Mailing Address

North Carolina Medical Board

Attn: Corporations

P.O. Box 20007

Raleigh, NC 27619‐0007

Physical/Delivery Address

North Carolina Medical Board

Attn: Corporations

1203 Front Street

Raleigh, NC 27609‐7533

Date:___________________

PC/PLLC Certificate #:_________________

Application For Certification And Registration Of A Professional Corporation With The North Carolina Medical Board Page 2