Professional Corporations Contact information Form - New York State ...
The University of the State of New York The State Education Department Office of the Professions Professional Corporations Unit op.corp/
Professional Practice Entity (PC, DPC, PLLC, etc.) Contact Information
Instructions All applicants must complete this contact form and submit it directly to the Office of the Professions at the address at the end of this form. Failure to do so will delay the corporate or business entity's application review.
1. Professional Practice Entity Name
2. Professional Practice Entity Address
Line 1
Line 2
Line 3
City
State
Country/ Province
ZIP Code
3. Contact Telephone Number
Area Code
Phone
5. Entity Type (PC, DPC, PLLC, etc.)
4. Contact Email
6. List all Professions Being Practiced by this Professional Practice Entity
7. Is this Professional Practice Entity Formed in Another State? If "yes", in what State(s)?
8. Is this Professional Practice Entity Already Formed in New York State? If "yes", Enter This Professional Practice Entity's PSC Number
9. Name of Contact Person
Yes
No
Yes
No
10. Relation of Contact Person to Corporation (i.e., owner, shareholder, officer, director, member manager, partner, attorney, or filing service)
11. This Information is Current as of (give full date)
Submit this form to: New York State Education Department, Office of the Professions, Professional Corporations Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Corporate Contact Information Form, April 2019
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