Free 10555.FH11 - Indiana

APPLICATION FOR REGISTRATION FOR AN ACCOUNTING PROFESSIONAL CORPORATION
State Form 10555 (R9 / 4-07) Approved by State Board of Accounts, 2007

Reset Form

INDIANA BOARD OF ACCOUNTANCY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

Professional accounting corporations may be organized for the practice of public accounting upon compliance with the Professional Corporation Act of 1983, IC 23-1.5 and IC 23-1.5-2-3(a)(1). Notification shall be given to the Secretary of State's Office and the Indiana Board of Accountancy within thirty (30) days after a change of business address of the professional corporation and the admission or withdrawal of a shareholder, giving the names and addresses submitted to the Secretary of State's Office and the Board of Accountancy. Pursuant to IC 25-2.1-5, a professional corporation must also obtain a permit to practice accountancy as a firm. * Your Federal Identification number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given. Numbers are made available to the Department of Revenue. FOR OFFICE USE ONLY
Application fee License number issued Date fee paid (month, day, year) Receipt number

Date license issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE
Federal ID number * Firm license number Date (month, day, year)

The proposed Corporation known as ___________________________________________________________________________________ is engaged in the practice of public accountancy 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 of corporation Address (number and street, city, state, and ZIP code) Telephone number E-mail address

(

)

List the names and addresses of all shareholders. State the type of license held, state of licensure, and registration number. 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 reverse side)

List the names and addresses of all 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 the 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 (month, day, year)