Application For Certificate Of Authority For Foreign Professional Corporation {CD 238}

Secretary of State OFFICE OF SECRETARY OF STATE CORPOR A TIONS DIVISION 2 Martin Luther King Jr. Dr. SE Suite 313 West Tower Atlanta, Georgia 30334 (404) 656 - 2817 sos.georgia.gov/corporations APPLICATIO N FO R CERTIFICAT E O F AUTHORITY FO R FOREIG N PROFESSIONAL CORPORATION IMPORTANT : P lease p rovide e mail address w hen completing this form. Primary Email Address: NOTICE TO APPLICANT: PRINT PLAINLY OR TYPE REMAINDER OF THIS FORM 1. Name of Professional Corporation Name Reservation Number (Optional) Date business commenced (or proposed to commence ) in Georgia: (NOTE: If the date provided here is more than 30 da y s prior the effective date of t h is application, a $500 penalty must be paid . P enalty is statutory and cannot be w aived by Secretary of Sta t e.) 2. Name of F iling P erson Address City State Zip Code Email Address Telephone Number 3. Principal Office Mailing Address (may be P.O. Box) City State Zip Code 4. Name of Registered Agent in Georgia Email Address Registered Office Street Address in Georgia ( p ost office box or mail drop not acceptable for registered office address) GA City County State Zip Code 5. Professional Jurisdiction ( Home State o r Country): Date of Incorporation in (Must match name on certificate of existence . ) Home Jurisdiction: 6. The purpose of the above - named professional corporation is to practice the profession of (choose one below): certified public accountancy professional engineering psychology podiatry architecture land surveying medicine and surgery veterinary medicine chiropractic law optometry registered professional nursing dentistry pharmacy osteopathy harbor piloting The corporation certifies that it is authorized to pursue such stated purpose in this state and in its state or coun try of incorporation. 7 . Officer / CEO Address City State Zip Code Officer / CFO Address City State Zip Code Officer / S ecretary Address City State Zip Code 8 . Effective Date: (Choose one) Upon filing Delayed effective date and/or time : (A delayed effective date must be within 90 days of the filing date.) 9 . NOTICE: Mail the following items to the Secretary of State at the above address. ( 1) This application ; (2) An ORIGINAL certificate of existence or good standing, not more than 90 days old, certified by the home state or country . (3) Filing fee of $225.00 pa y able to of F iling fees are non - refundable. (4) If applicable, a copy of the Signature of Authorized Person Date Print name Title FORM 23 8 ( Rev. 10/2018 ) American LegalNet, Inc. www.FormsWorkFlow.com