Free 47914.PDF - Indiana

APPLICATION FOR REGISTRATION FOR REAL ESTATE PROFESSIONAL CORPORATION
State Form 47914 (R2 / 7-02) Approved by State Board of Accounts, 2002 Indiana Real Estate Commission

Control number

FEE: $25.00
INSTRUCTIONS: Mail check or money order payable to: Indiana Professional Licensing Agency 302 West Washington Street, Room E034 Indianapolis, IN 46204

Professional Real Estate Corporations may be organized, upon compliance with the Professional Corporation Act of 1983, IC 23-1.5 and IC 23-1.5-2-3(a)(6). Notification shall be given to the Secretary of State's office and the Indiana Real Estate Commission within thirty (30) days after a change of business address of the professional corporation, and the admission or withdrawal of shareholder, giving the names and addresses submitted to the Secretary of State's office and the Indiana Real Estate Commission.

* Your Federal I.D. number is requested pursuant to IC 4-1-8-1 and is not mandatory that it be given. Numbers are made available to the Indiana Department of Revenue.
Federal I.D. number * Date (month, day, year)

The proposed Corporation known as _________________________________________________________________________ is engaged in the practice of Real Estate in this state and hereby makes application for registration pursuant to the Professional Corporation Act of 1983, IC 23-1.5. The principal office of the Corporation is:
Name Telephone number

(
Address (number and street, city, state, ZIP code)

)

List names and addresses of all shareholders. At least one (1) shareholder must be licensed in Indiana. Attach an additional 8 1/2" x 11" sheet if necessary.
Name and Address Type of License Held State of Licensure Registration Number

(Continued on the reverse side)

List names and addresses of all the officers. State the type of license held, state of licensure, and registration number. The secretary and treasurer also need to be listed but are not required to be licensed in Indiana or another state. Attach an additional 8 1/2" x 11" sheet if necessary.
Name and Address Type of License Held State of Licensure Registration Number

List names and addresses of all the directors. State the type of license held, state of licensure, and registration number. Attach an additional 8 1/2" x 11" sheet if necessary.
Name and Address Type of License Held State of Licensure Registration Number

I hereby certify that the above information is true and correct.
Signature of Indiana licensed shareholder Date signed