Form Pc - Foreign Professional Corporation Annual Report

P C

FEDERAL IDENTIFICATION

NO. _____________________

Fee: $85.00

The Commonwealth of Massachusetts

William Francis Galvin

Secretary of the Commonwealth

One Ashburton Place, Boston, Massachusetts 02108-1512

FOREIGN PROFESSIONAL CORPORATION ANNUAL REPORT

(General Laws, Chapter 156A, Section 18)

1. Exact name of corporation:

2. The corporation was organized under the laws of the state of:

3. Full address of principal office in Massachusetts:

4. The full address of its Massachusetts office, if any:

5. Exact name and full address of resident agent:

6. Date of the end of corporation’s last fiscal year:

7. The capital stock of each class as of the end of its last fiscal year was as follows:

Without par value

With par value

Type

Number of shares

Type

Number of shares

Par value

Common:

Preferred:

8. The names and business addresses of the officers and directors of the corporation, and the expiration dates of their terms of

office are as follows:

NAME

BUSINESS ADDRESS

EXPIRATION OF TERM OF OFFICE

President:

Treasurer:

Clerk/Assistant Clerk:

Directors:

9. The names and residential addresses of all shareholders, whether individual, partners, or professional corporations are as follows:

NAME

RESIDENTIAL ADDRESS

I, _________________________________________ the undersigned, being the _______________________________________

of the above-named corporation, do hereby certify, pursuant to Massachusetts General Laws, Chapter 156A, Section 18, that the

above listed shareholders, and all the partners of a general partnership which is a shareholder of the corporation, are duly

licensed to render one or more professional services for which the corporation was organized, or are professional corporations

authorized to render such professional services, and that a copy of this report is being sent to the appropriate regulating board. I

further certify that, in compliance with the General Laws, Chapter 156A and 181, all the information is true and correct as of the

dates shown.

SIGNED UNDER THE PENALTIES OF PERJURY, this ___________ day of _______________________________ , 20 _________ .

___________________________________________ , Signature _______________________________________________ , Title

Note: If additional space is required, use 8 1/2 x 11 plain white paper and attach to this document.

*If the corporation is organized wholly to do business outside Massachusetts, give the location of that office as well.

156fpcar 4/5/00

Form Pc - Foreign Professional Corporation Annual Report - 2000

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