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This is a Arizona form that can be used for Corporation within Secretary Of State.
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ARIZONA CORPORATION COMMISSION CORPORATIONS DIVISION Phoenix Address: 1300 West Washington Tucson Address: 400 West Congress Phoenix, Arizona 85007-2929 Tucson, Arizona 85701-1347 PROFIT CERTIFICATE OF DISCLOSURE A.R.S. 10-202.D EXACT CORPORATE NAME A. Has any person serving either by election or appointment as officer, director, trustee, incorporator and personsng or hol controlldii ng over 10% of theissued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation: 1. Been convicted of a felony involving a transaction in sitiesecur, consumer fraud or antitrust in any state or federal jurisdiction within the seven-year period immediately preceding the execution of this Certificate? 2. Been convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by false preor rteenssterasin, t of trade or monopoly in any state or federal jurisdiction within the seven-year period immediately preceding the execution of this Certifate?ic 3. Been or are subject to an injunction, judgment, decree or permanent order of any state or federal court entered wivethn-yein thaer pese riod immediately preceding the execution of this Ceirtcatif e wherein such injunction, judgment, decree or permanent order: (a) Involved the violation of fraud or registration provisions of theities sec lawur s of that jurisdiction?; or (b) Involved the violation of the consumer fraud laws of that jurisdiction?; or (c) Involved the violation of thetitr aunst or restraint of trade laws of that jurisdiction? Yes No B. IF YES, the following information MUST be attach:ed 1. Full name, prior name(s) and aliases, if used. 6. Social Security number. 2. Full birth name. 7. The nature and description of each conviction or judicial action, 3. Present home address. date and location, the court and public agency involved and file or 4. Prior addresses (for immediate preceding 7-year period). cause number of case. 5. Date and location of birth. C. Has any person serving as an officer, director, trustee or incorporator of the corporation served in any such capad or ccity or ontheroll led over 20% of the issued and outstanding common shares, or 20% of any other proprietary, beneficial or membership interest in any otrahetior n whicorpoch has been placed in bankruptcy, receivership or had i charttser revoked, or administratively or judicially dissolved by any state or jusdriiction?Yes No IF YOUR ANSWER TO THE ABOVE QUESTION IS "YES", YOU MUST ATTACH THE FOLLOWING INFORMATION FOR EACH CORPORATION: 1. Name and address of the corporation. 3. State(s) in which the corporation: 2. Full name (including aliases) and address of each person (a) Was incorporated. (b) Has transacted business. involved. 4. Dates of corporate operation. 5. Date and case number of Bankruptcy or date of revocation/administrative dissolution.D. The fiscal year end adopted by the corporation is . Under penalties of law, thundee rsigned incorporator(s)/officer(s) declare(s) that I(we) have examined this Certificate, including any attachmentths,e and to best of my(our) knowledge and belief it is true, correct and complete, and hereby declare as indicated above. THE SIGNAT MUREUST( BES) DATEDWITHIN THIRTY (30) DAYS OF THE DELIVERY DATE. BY BY PRINT NAME PRINT NAME TITLE DATE TITLE DATE DOMESTIC CORPORATIONS: ALL INCORPORATORS MUST SIGN THE INITIAL CERTIFICATE OF DISCLOSURE. If within sixty days, any personbecomes an officer, director, trustee or person controlling or holding over 10% of the issued and outstanding shares aor 10%ny othe of r proprietary, beneficial,or membership interest in the corporation and the person was not included in this disclosure, the corporation must fileD aEnD AME certifNicate signed byat least one duly authorized officer of the corporation. FOREIGN CORPORATIONS: MU ST BE SIGNED BY AT LEAST ONE DULY AUTHORIZED OFFICER OF THE CORPORATION. CF: 0022 - Business Corporations Rev: 04/04