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APPLICATION FOR REGISTRATION UNDER THE PROFESSIONAL CORPORATION ACT
State Form 50160 (R2 / 2-06) Approved by State Board of Accounts, 2006

PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 232-2960 www.pla.IN.gov

INSTRUCTIONS:

Please type or print. FOR OFFICIAL USE ONLY

Application fee

Date fee paid (month, day, year)

Receipt number

Registration number

DO NOT WRITE ABOVE THIS LINE
Name of corporation Principal office address (number and street or rural route, city, state, and ZIP code)

Telephone number (daytime)

(

)

Email address

Website address

Check one corporation type:

Acupuncture Athletic Training Audiology Chiropractic Dental Dental Hygiene Dietetics

Environmental Health Health Facility Administration Hearing Aid Dealer Hypnotism Marriage and Family Therapy Medical Mental Health Counseling

Nursing Occupational Therapy Occupational Therapy Assistant Optometry Pharmacy Physical Therapy Physical Therapy Assistant

Physician Assistant Multidisciplinary Podiatry Psychology Respiratory Care Social Work Speech-Language Pathology Veterinary

NOTE: Complete and return this application with the fee payable to the Professional Licensing Agency. A certificate of registration will be issued from this office which you must file with the Office of the Secretary of State of Indiana, State House, Indianapolis, Indiana. THIS APPLICATION DOES NOT CONSTITUTE A CERTIFICATE AND CANNOT BE USED FOR FILING WITH THE INDIANA SECRETARY OF STATE. PLEASE NOTE: THE REGISTRATION PROCESS WILL NOT BE COMPLETE UNTIL THE PROFESSIONAL LICENSING AGENCY RECEIVES A COPY OF THE ARTICLES OF INCORPORATION CERTIFIED BY THE OFFICE OF THE SECRETARY OF STATE. We suggest that you submit an extra copy of the Articles of Incorporation to the Office of the Secretary of State for this purpose. Notification shall be given to the Professional Licensing Agency within thirty (30) days after a change of business address of the Corporation and the admission or withdrawal of a shareholder. Notification shall include the names and addresses of both the transferrer and transferee shareholders. In addition, a certified copy of all amendments to the Articles of Incorporation must be submitted to the Professional Licensing Agency. List name, address, and licensure data for each shareholder, officer and director of the proposed corporation. Check the appropriate box in the last column. Attach additional 8-1/2 x 11 sheet if necessary.
NAME AND ADDRESS PROFESSION INDIANA LICENSE NUMBER OTHER STATE LICENSE (State and License #) STATUS Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director (Continued on the reverse side)

NAME AND ADDRESS

PROFESSION

INDIANA LICENSE NUMBER

OTHER STATE LICENSE (State and License #)

STATUS Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director Shareholder Officer Director

The undersigned hereby make(s) application for a certificate to establish and operate a professional corporation. This application is to show that each proposed shareholder and director of the corporation is a reputable and responsible health care professional as required by IC 23-1.5-1-8 and IC 23-1.5-2-3. The corporation further agrees to comply with IC 23-1.5, and agrees that the corporation will be organized in compliance with the statutes and regulations of the relevant licensing authorities. I / We hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete, and correct. If this application is signed by an incorporator who is not a shareholder, the incorporator further certifies that the incorporator has been duly granted the authority by the shareholders and directors of the proposed corporation to sign this application.
Signature of applicant Printed name of applicant Signature of applicant Printed name of applicant

Incorporator
Date signed (month, day, year) Signature of applicant Printed name of applicant

Shareholder

Incorporator
Date signed (month, day, year) Signature of applicant Printed name of applicant

Shareholder

Incorporator
Date signed (month, day, year)

Shareholder

Incorporator
Date signed (month, day, year)

Shareholder

PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 232-2960 Fax: (317) 233-4236 www.pla.IN.gov

VERIFICATION OF STATE LICENSURE FOR INDIANA PROFESSIONAL CORPORATION REGISTRATION APPLICATION

YOU DO NOT NEED TO COMPLETE THIS FORM IF YOU ARE LICENSED TO PRACTICE IN INDIANA.

Privacy Notice: This state agency is requesting disclosure of your Social Security number, under IC 4-1-8-1. This form cannot be processed without it. INSTRUCTIONS FOR PRACTITIONERS: Please type or print. Complete the top section. Make copies and send to each state in which you hold a license. Have the state(s) send this form directly to the Professional Licensing Agency. This form is to be used only for verification of licensure status for the purpose of registering a professional corporation. It cannot be used for applying for verification when applying for a license. The Professional Licensing Agency will accept the standard state verification form provided by another state in lieu of this form.

Name (last, first, middle) Type of health profession license held Social Security number License number Date of issuance (month, day, year) Date of birth (month, day, year)

I hereby authorize the State of _____________________________, to furnish to the Professional Licensing Agency the information below.
Signature of practitioner

Practitioner: Do not write below this line.
License number License is current and in good standing? Date of issuance (month, day, year) Expiration date (month, day, year) Profession Any derogatory information?

Yes

No

Yes

No

IF LICENSE HAS BEEN ENCUMBERED IN ANY WAY, PLEASE PROVIDE CERTIFIED COPIES OF ALL RELATED DOCUMENTS. PLEASE AFFIX BOARD SEAL. Form completed by:
Printed name Signature State Board name Title Date (month, day, year)