FORM MUST BE TYPED FORM MUST BE TYPED
The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Certifi cate by Regulatory Board**
(General Laws, Chapter 112 or 221)
In compliance with General Laws, Chapter 156A, Section 7, the
__________________________________________________________
(Exact name of board)
____________________________________________________________
hereby certifi es that in connection with the incorporation of ____________________________________________________________hereby certifi es that in connection with the incorporation of
,
(Exact name of corporation)
a professional corporation formed to render
___________________________________________________________________
services,
(Type of professional service to be rendered)
the below listed incorporators, offi cers, directors, and shareholders are duly licensed or admitted to practice the profession listed above.
INCORPORATORS RESIDENTIAL ADDRESS
OFFICERS RESIDENTIAL ADDRESS
DIRECTORS RESIDENTIAL ADDRESS
SHAREHOLDERS RESIDENTIAL ADDRESS
SIGNED this
_______________________________
day of
_____________________________________________
day of _____________________________________________ day of
, 20
__________
,
by
_________________________________________________________________________________________
by _________________________________________________________________________________________by
, *Chairman / *Clerk.
*Delete the inapplicable word.
**Certain regulatory boards may require a fee for the issuance of this certifi cate.
112crgbd 7/29/04