Application For Certification And Registration Of A Professional Corporation With The North Carolina Medical Board (Page 3 of 4) in pdf

Application For Certification And Registration Of A Professional Corporation With The North Carolina Medical Board Page 3

CERTIFICATE OF INCORPORATORS AND

APPLICATION FOR A CERTIFICATE OF REGISTRATION FOR A PROFESSIONAL

CORPORATION FOR THE PRACTICE OF MEDICINE

The undersigned, being all of the incorporators of_____________________________________________

a professional corporation about to be incorporated under the laws of North Carolina for the purpose of practicing

medicine, hereby certify to the North Carolina Medical Board:

All persons who are incorporators and all persons who, to the best of our knowledge and belief, will be

original shareholders or who will be employed by said corporation to practice medicine for said corporation

are duly licensed to practice medicine in North Carolina. The names and addresses of all shareholders

are:

SHAREHOLDER, TITLE

P.O. BOX or STREET

CITY, STATE, ZIP CODE

2. To the best of our knowledge and belief, no disciplinary action is pending or threatened in any

jurisdiction against any of the persons listed above.

3. We represent that the corporation will be conducted in compliance with the Professional

Corporation Act and with the Regulations of the North Carolina Medical Board.

4. Application is hereby made for a Certificate of Registration to become effective when the Articles of

Incorporation are filed with the Secretary of State.

Incorporating Shareholder

State of___________________

County of__________________

I, _______________________, a Notary Public for the above named County and State, do hereby

certify that ______________, _______________, _____________, ___________, _____________

personally appeared before me this day and acknowledged the due execution of the foregoing

instrument. Witness my hand and official seal this the ______day of__________, 20_____

________________________________Notary Public

________________

(Seal)

My Commission expires: ______________________.

NCMB-PC-01

Application For Certification And Registration Of A Professional Corporation With The North Carolina Medical Board Page 3