Foreign State Qualifications - Q - Montero Corporate Services

Qualification Questionnaire

Form Completed by*
E-Mail Address*
Bill to:
Bill to Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Qualification State*
Corporation Name*
Please attach copy of Articles of Incorporation
FEIN for Entity*
Corporation Type*
Nature of Business*
Fiscal Year End*
Directors/Members

Director/Member*

list add

list remove

Officers
President*
Secretary*
Treasurer (CFO)*
Additional Officers

List here

Name	Title

Address of Corporation*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Fax
Mailing Address*
- Same
- Different
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Issuance of Stock

Shareholders

Shareholder Name	Number of Shares	Dollar Amount

If more than 4 Shareholders-Please provide Name/Number of Shares/Dollar Amount or Value of Consideration for each issuance
Additional information (if any)
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