Chiropractic Professional Corporation

Information Questionnaire

Desired Name of Corporation *

First Name *

Middle Name *

Last name *

Social Insurance Number *

Phone *

Address *

Street Address

City

State

Country

Postal Code

Shareholders Information

Shareholder 1 | name *

Shareholder 1 | phone number *

Shareholder 1 | Address *

Shareholder 2 | name *

Shareholder 2 | phone number *

Shareholder 2 | Address *

Other Shareholders information *

Please input the rest of the shareholders names, phone number and address.

Corporate Bank

Bank 1 | Name *

Bank 1 | Branch Address *

Bank 1 | Desired Year End of Corporation *

Bank 2 | Name *

Bank 2 | Branch Address *

Bank 2 | Desired Year End of Corporation *

Other Banks information *

Please add other banks names, branch addresses and desired end of year coporation

CCO (College of Chiropractors of Ontario) Information *

Clinics

Clinic 1 | Name *

Clinic 1 | Address *

Clinic 2 | Name *

Clinic 2 | Address *

Other Clinics information

Please input other clinics names and addresses