Hospital Certificate Of Approval Page 8
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18F-62092 (Rev. 07/08)
Page 8
Holding (i.e., what the owner owns):
Operations
Building
Land
B. TYPE OF ORGANIZATION
Check type of ownership.
Governmental
Proprietary
Voluntary Non-Profit
City
Sole Proprietary
Corporation
County
Partnership
Church
State
Corporation
Association
Federal
Limited Liability Company
Church / Corporation
City / County
Limited Liability Partnership
Private Non-Profit
Tribal
Trust
Limited Liability Company
Limited Liability Partnership
Trust
If Incorporated, Date Incorporated
C. INTERESTED PARTIES
List all names, principal business addresses and the percentage of ownership interest of all officers, directors,
stockholders owning 5% or more of stock, and members, partners, and all other persons having authority or
responsibility for the operation of the organization. For non-profit organizations or governmental organizations, list the
names and principal business address of all officers, directors, and board members. Attach additional pages if
necessary.
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
ADVERTISEMENT
0 votes
Related Articles
Related forms
Podiatry Form 4pgy - Certification Of Approved Podiatric Postgraduate Training - New York The State Education Department
Legal
Certificate Of Cancellation Of Limited Partnership - Delaware Division Of Corporations, Certificate Of Cancellation Of Foreign Limited Partnership - Delaware Division Of Corporations
Legal
Related Categories
Parent category: Business