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Massachusetts Corporation Regulatory Board Certificate Form

In the case of activities that required approval from specific regulatory bodies in the Commonwealth, the Massachusetts Corporation Regulatory Board Certificate Form has to be completed and submitted.

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FORM MUST BE TYPEDFORM 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	 ____________________________________________________________	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
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