Free 44867.PDF - Indiana

APPLICATION FOR ARCHITECT CORPORATION LICENSE
State Form 44867 (R2 / 1-01) Approved by the State Board of Accounts, 2001 Check one (1) corporation type:

FOR OFFICE USE ONLY CN OU NM TB RE OR L FEDERAL IDENTIFICATION NUMBER
Your Federal Indentification number is being requested in accordance with IC 4-1-8-1. It is not mandatory that this number be given. If given , it will be made available to the Indiana Department of Revenue.

Architect

Landscape Architect

Architect / Landscape Architect

INSTRUCTIONS: Professional architect and landscape architect corporations may be organized for the practice of architecture 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, IN 46204. Notification shall be given to the Secretary of State's office and the Indiana Board of Registration for Architects within thirty (30) days after a change of business address of the Corporation and the admission to or withdrawal of a shareholder, giving the names and addresses of both and transferer and transferee shareholders. 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 Registration for Architects. One shareholder shall execute Affidavit of Shareholder on the back of this application.

FEE $25.00
Make check or money order payable and mail to: INDIANA PROFESSIONAL LICENSING AGENCY INDIANA GOVERNMENT CENTER SOUTH 302 W. WASHINGTON STREET RM E034 INDIANAPOLIS IN 46204

CORPORATION INFORMATION
Date Federal Identification number

Gentlemen: The Corporation known as _______________________________________________________________________________ is engaged in the practice of architecture and hereby makes application for registration pursuant to the Professional Corporation Act of 1983, IC 23-1.5.
Name of principal office of corporation Telephone number

(
Address (number and s treet , cit y, stat e, Z IP code)

)

SHAREHOLDER / DIRECTOR / OFFICER PRACTICING OR LICENSED (Designate Shareholder, Director or Officer)
Name of individual Architect registration number Address (number and street, city, state, ZIP code)

Name of state of original issue

Registration number of original issue

(C hec k app ropr ia t e bo x)

Shareholder
Name of individual

Director

Officer
Architect registration number Registration number of original issue Address (number and street, city, state, ZIP code)

Name of state of original issue

(C hec k app ropr ia t e bo x)

Shareholder
Name of individual

Director

Officer
A r ch it e ct r egi s t r at i on num ber Address (number and street, city, state, ZIP code) Registration number of original issue

Name of state of original issue

(C hec k app ropr ia t e bo x)

Shareholder
Name of individual

Director

Officer
Architect registration number Registration number of original issue Address (number and street, city, state, ZIP code)

Name of state of original issue

(C hec k app ropr ia t e bo x)

Shareholder
Name of individual

Director

Officer
Architect registration number Registration number of original issue Address (number and street, city, state, ZIP code)

Name of state of original issue

(C hec k appr opr iat e box )

Shareholder

Director

Officer
(Continued on reverse side)

SHAREHOLDER / DIRECTOR / OFFICER PRACTING OR LICENSED (Designate Shareholder, Director or Officer)
Name of individual Architect registration number Address (number and street, city, state, ZIP code)

Name of state of original issue

Registration number of original issue

( Ch eck ap prop ri at e b ox)

Shareholder
Name of individual

Director

Officer
Architect registration number Registration number of original issue Address (number and street, city, state, ZIP code)

Name of state of original issue

( Ch eck ap prop ri at e b ox)

Shareholder
Name of individual

Director

Officer
Architect registration number Registration number of original issue Address (number and street, city, state, ZIP code)

Name of state of original issue

( Ch eck ap prop ri at e b ox)

Shareholder
Name of individual

Director

Officer
Architect registration number Registration number of original issue Address (number and street, city, state, ZIP code)

Name of state of original issue

( Ch eck ap prop ri at e b ox)

Shareholder
Name of individual

Director

Officer
Architect registration number Registration number of original issue Address (number and street, city, state, ZIP code)

Name of state of original issue

( Ch eck ap prop ri at e b ox)

Shareholder

Director

Officer

AFFIDAVIT OF SHAREHOLDER A CORPORATION OF PROFESSIONAL ARCHITECTS OR REGISTERED LANDSCAPE ARCHITECTS AND / OR PROFESSIONAL ARCHITECTS AND REGISTERED LANDSCAPE ARCHITECTS

STATE OF COUNTY OF

}

(Notary Seal) SS:

I, _____________________________________________________________________ being duly sworn, deposes and says that he/she is a registered Architect / Landscape Architect, and his/her office and principal place of business is located at _________________________________________________________. That he/she is a shareholder of the corporation known as ________________________________, that all statements made in this application regarding the said corporation are true; that said corporation has complied with all provisions of corporation laws of this State applicable thereto; that each shareholder of said corporation is a registered Architect or Landscape Architect in good standing; that each officer is a registered Architect or Landscape Architect in good standing; and each director is a qualified person as defined by IC 25-4-2.

Signature of applicant

Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public

Date subscribed and sworn to (Notary Public)

County of residence

Date commission expires