Certificate By Regulatory Board Form - The Commonwealth Of Massachusetts
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1The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Certifi cate by Regulatory Board**
FORM MUST BE TYPED
FORM MUST BE TYPED
(General Laws, Chapter 112 or 221)
In compliance with General Laws, Chapter 156A, Section 7, the __________________________________________________________
(Exact name of board)
hereby certifi es that in connection with the incorporation of ____________________________________________________________
hereby certifi es that in connection with the incorporation of ____________________________________________________________
hereby certifi es that in connection with the incorporation of
,
(Exact name of corporation)
a professional corporation formed to render ___________________________________________________________________ services,
(Type of professional service to be rendered)
the below listed incorporators, offi cers, directors, and shareholders are duly licensed or admitted to practice the profession listed above.
INCORPORATORS
RESIDENTIAL ADDRESS
OFFICERS
RESIDENTIAL ADDRESS
DIRECTORS
RESIDENTIAL ADDRESS
SHAREHOLDERS
RESIDENTIAL ADDRESS
SIGNED this _______________________________ day of _____________________________________________
day of _____________________________________________
day of
, 20 __________ ,
by _________________________________________________________________________________________
by _________________________________________________________________________________________
by
, *Chairman / *Clerk.
*Delete the inapplicable word.
**Certain regulatory boards may require a fee for the issuance of this certifi cate.
112crgbd 7/29/04
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