Free 50792.FH11 - Indiana

APPLICATION FOR REGISTRATION FOR PROFESSIONAL CORPORATION
State Form 50792 (R / 10-06) Approved by State Board of Accounts, 2006

State Board of Registration for Architects and Landscape Architects State Board of Registration for Land Surveyors State Board of Registration for Professional Engineers

INDIANA PROFESSIONAL LICENSING AGENCY 402 W. Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3022 E-mail: [email protected] www.pla.IN.gov

APPLICATION NUMBER APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE LICENSED ISSUED (month, day, year)

DO NOT WRITE ABOVE THIS LINE

Check Corporation type(s):

Architecture Professional Engineer

Landscape Architecture

Land Surveyor

Professional Architecture, Landscape Architecture, Land Surveyor, and / or Professional Engineer Corporations may be organized for the practice of architecture, landscape architecture, land surveying, and / or professional engineering upon compliance with the Professional Corporation Act of 1983, IC 23-1.5 and IC 23-1.5-2-3(a)(2). Notification shall be given to the Secretary of States office and the State Board of Registration for Architects and Landscape Architects, State Board of Registration for Land Surveyors, and / or State Board of Registration for Professional Engineers 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 States office and the State Board of Registration for Architects and Landscape Architects, State Board of Registration for Land Surveyors, and / or State Board of Registration for Professional Engineers.

* Federal ID number is requested by this agency in accordance with IC 4-1-8-1 and is not mandatory that it be given. Numbers are made available to the Department of Revenue.
Federal ID number * Date (month, day, year)

The proposed Corporation known as is engaged in the practice of architecture, landscape architecture, land surveying and / or professional engineering [circle professional service(s) offered] 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 Telephone number

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

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(Continued on the reverse side)

List 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

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 (month, day, year)