IMPORTANT INFORMATION DO NOT USE THIS APPLICATION IF: ! The corporation is formed to practice law. Contact the Illinois Supreme Court, Clerk's Office at 217/782-2035 for an application. ! The corporation is formed to practice the profession of real estate. Contact the Department of Financial and Professional Regulation, Division of Banks and Real Estate, Consumer Services at 217/782-3414 for an application. The application is also available on the Department's Web Site at: www.idfpr.com. Upon accessing the Web Site, click on the Division of Banks and Real Estate. ! The entry is a Medical LLC. After filing with the Illinois Secretary of State you need not also file with the Illinois Department of Financial and Professional Regulation. ! The corporation provides architectural, professional engineering, structural engineering and/or land surveying services. After filing your Articles of Incorporation with the Illinois Secretary of State, you must file a Design Firm Application with the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation. The application is available on the Department's Web Site at: www.idfpr.com. Upon accessing the Web Site, click on the Division of Professional Regulation. ! If you are an Out of State Professional Service Corporation seeking to do business in Illinois and all officers, directors and shareholders are NOT individually licensed in Illinois, you must obtain a letter of compliance from the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation. The letter of compliance concerns the Illinois licensure of those persons from the corporation who will perform the professional services in Illinois. The letter of compliance must be filed with the Illinois Secretary of State along with their Foreign Corporation Application. STATUTORY REQUIREMENTS - Medical Corporation 1. Only physicians and surgeons and chiropractors licensed under the Illinois Medical Practice Act may apply for a Medical Corporation Registration. All officers, directors and shareholders of the Medical Corporation MUST hold an active Illinois physicians and surgeons or chiropractor license. 2. The corporation name must end with the word "chartered" or "limited" or the abbreviation "Ltd." or the words "Service Corporation or the abbreviation "S.C." The Medical Corporation Registration will be issued in the same name as on the Articles of Incorporation as filed with the Illinois Secretary of State. The purpose clause must specify "medical corporation." 3. A separate application must be submitted for each business location in Illinois. 4. If the company is using more than one d/b/a and the address is different than that of the parent company, then a new application is required for each additional d/b/a filed with the Illinois Secretary of State. STATUTORY REQUIREMENTS - Professional Service Corporation 1. A Professional Service Corporation is a corporation organized solely for the purpose of rendering ONE CATEGORY of professional service or related professional services. All shareholders, directors, officers, agents and employees (other than ancillary personnel and/or the secretary of the corporation) MUST BE LICENSED under the same professional licensure act. EXCEPTION: A combination of the following services may be provided by a Professional Service Corporation: (a) the practice of medicine in all of its branches, (b) the practice of podiatry (c) the practice of dentistry (d) the practice of optometry. 2 The corporate name must end with the word "chartered" or Limited" or the abbreviation "Ltd." or with the words "Professional Corporation" or the abbreviation "Prof. Corp." or the initials "P.C." The Professional Service Corporation Registration will be issued in the same name as appears on the Articles of Incorporation as filed with the Illinois Secretary of State. 3. A separate application must be submitted for each business location in Illinois. 4. If the company is using more than one d/b/a and the address is different than that of the parent company, then a new application is required for each additional d/b/a filed with the Illinois Secretary of State. INSTRUCTIONS/CHECKLIST FOR COMPLETING THE APPLICATION All Medical Corporation and Professional Service Corporation registrations expire on December 31 of each year, regardless of the date on which the registration was issued by the Department of Financial and Professional Regulation, Division of Professional Regulation. " Complete all information on the Application for a Medical or Professional Service Corporation Registration. Make sure the application bears the same name that appears on the Articles of Incorporation as filed with the Illinois Secretary of State. " Sign and date the application. " Submit a complete copy of the Articles of Incorporation as filed with the Illinois Secretary of State. " Submit a registration fee of $50 made payable to the Illinois Department of Financial and Professional Regulation. Fees are not refundable. " Mail the original application, copy of the Articles of Incorporation and/or a copy of the Assumed Name document as issued by the Illinois Secretary of State if using a d/b/a, and fee payment to: Illinois Department of Financial and Professional Regulation, Division of Professional Regulation, P.O. Box 7007, Springfield, IL 62791. If assistance is needed, direct your request to the following telephone number: Department of Financial and Professional Regulation 217-782-8556 Telecommunication for the Deaf 217-524-6735 When an operator answers, state the profession for which you are applying and that you need assistance with your application. The Illinois Department of Financial and Professional Regulation, Division of Professional Regulation, maintains a Web Site at www.idfpr.com. You may accomplish a number of tasks via the Web Site including: License Look-up; download and print professional licensure acts and rules and application materials; disciplines imposed by the Department; etc. IL486-0513 07/08 (PC) American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICIAL USE ONLY APPLICATION FOR A MEDICAL OR PROFESSIONAL CORPORATION REGISTRATION IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure under 805 ILCS 10/1 et. seq. or 805 ILCS 15/1 et. seq. (Illinois Compiled Statutes). Disclosure of this information is VOLUNTARY. However, failure to comply may result in this form not being processed. NOTE: A separate application must be completed for each address listed in the purpose clause of the Articles of Incorporation. 1. NAME OF CORPORATION (exactly as it appears on the Articles of Inc.) 2. TYPE OF REGISTRATION 3. FEIN NUMBER #Medical Corporation #Professional Service Corporation 4. OFFICE ADDRESS (Street Address, City, State, ZIP Code) 5. COUNTY 6. DATE CORPORATION FORMED 7. OFFICE TELEPHONE NUMBER 8. IDENTIFICATION OF SHAREHOLDERS, DIRECTORS, OFFICERS, AGENTS, AND EMPLOYEES OTHER THAN ANCILLARY PERSONNEL NAME ADDRESS (City, State, ZIP Code) ILLINOIS LICENSE NUMBER 9. IF AN ATTORNEY LICENSED TO PRACTICE LAW IN ILLINOIS IS ACTING AS INITIAL INCORPORATOR ON BEHALF OF THE CORPORATION, PROVIDE THE ATTORNEY'S NAME, BUSINESS ADDRESS AND TELEPHONE NUMBER. ATTORNEY NAME BUSINESS ADDRESS TELEPHONE NUMBER 10. The corporation named in this application is using an assumed name. (An assumed name for a Medical Corporation is any name that does not consist of the surname of any present or former shareholder. An assumed name for a Professional Service Corporation is any name that does not consist of the full or last name of one or more of its shareholders.) #Yes #No 11. The assumed name and the name of the corporation's shareholders have been filed and recorded with the Recorder of the County in which the principal office is located. The name of the County is: _____________________________________________________________ #Yes #No 12. The Articles of Incorporation have been filed with the Illinois Secretary of State and a copy of the complete filed Articles is attached. #Yes #No Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection therewith, and to the best of my knowledge they are true, correct and complete. Signature of Applicant Date I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. My signature above authorizes the Department of Financial and Professional Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this will be done only if the amount submitted is greater than the required fee hereunder, but in no event shall such reduction be made in an amount greater than $50. IL486-0513 07/08 (PC) American LegalNet, Inc. www.FormsWorkflow.com