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HEALTH STUDIO REGISTRATION

Demographics

Health Studio Name

Address 1

Address 2

Zip

City

State

Mailing Address

Check if mailing address is the same as above address. If not, please enter it here.

Address 1

Address 2

Zip

City

State

Telephone Number

Business Structure

Date of Formation

State of incorporation

Date on which you registered to do business in Alabama

Date on which you commenced business in Alabama

EIN

FEIN

First Name of the resident agent

Last Name of the resident agent

Telephone number resident agent

Address of the resident agent

Address 1

Address 2

Zip

City

State

List the name, address, date, and telephone number of all business locations where the applicant is providing or will provide health studio services:

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Documents

Attach copies of each health studio services agreement or contract used or scheduled to be used at the locations

Bond

Bond expiration date

Indefinite

Third Party Filer

Are you a third party filer authorized to represent this organization

Yes

Preview

Affirm And Submit

By providing my electronic signature, I hereby affirm that the information on this document and in any attachments is true and correct. I further certify that I am authorized to submit this form on behalf of the applicant.

I also understand that I am under a continuing obligation to notify the Office of the Attorney General of any change in the information provided, and that according to § 13A-9-76(a)(4) of the Code of Alabama, any fraud or misrepresentation when submitting an application is grounds for legal action, which may result in civil penalties along with attorney’s fees and costs.

Date :

Signatory Title :

Signatory Affirmation :