Free CFD-03 - Arkansas

Arkansas Secre t a ry of State
Charlie Daniels
State Capitol · Little Rock, Arkansas 72201-1094 501-682-3409 · www.sos.arkansas.gov

Business & Commercial Services, 250 Victory Building, 1401 W. Capitol, Little Rock I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days.
NOTE: Subsequent annual reports may be filed within thirty (30) days of the anniversary date of this filing.

Health Spa Consumer Protection Act
Date: Name of Health Spa: Street Address:

(Act 264 of 1989) Annual Registration Statement
(Please Submit in Duplicate)

The name and addresses of all officers, directors and stockholders of the Health Spa as follows:
Name Position Held Address

(Attach separate list if necessary) Name of Health Spa's parent corporation, if applicable: Street Address:

The names and street addresses of all officers, directors and stockholders of the Health Spa's parent corporation are as follows:
Name Position Held Address

(Attach separate list if necessary) The types of facilities available are as follows:
Name, street address and telephone number of a contact person responsible for filing annual registration:

NAME
(Signature of Contract Person)

STREET ADDRESS
(Telephone Number)

ADDRESS:
City State ZIP

CFD-03 Rev. 4/06