Name(s) and occupation(s) of proposed Board of Directors:
Name(s) and occupation(s) of proposed Officers or Members:
Names and license numbers of Licensed Clinical Mental Health Counselor Associates, Licensed Clinical Mental Health Counselors
and Licensed Clinical Mental Health Counselor Supervisors employed by the organization:
Names and duties of persons other than the ones listed above that are employed or to be employed by the organization:
We attest, to the best of our knowledge and belief that no disciplinary action is pending in any jurisdiction against any of the
licensed incorporators, officers, directors, shareholders, or employees of this organization. The undersigned acknowledges that
the corporation or company is being organized under the provisions of the North Carolina General Statutes.
Submitted by (incorporator(s) or organizer(s)):
Print name Signature
Print name Signature
Print name Signature
Print name Signature
STATE OF NORTH CAROLINA
County of
I HEREBY CERTIFY THAT the above incorporator(s) or organizer(s) personally appeared before me this day and stated that they had
read the foregoing Certificate of Registration Application and that the statements contains therein are true.
Signed before me this day of in the year .
Notary Public My commission expires
SEAL
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
