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Form 3009--General Information
(Amended Statement Regarding Membership Totals and Cost)

The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information provided are not substitutes for the advice and services of an attorney.

Commentary A health spa certificate holder must amend its Health Spa Registration Application no later than the 90th day after the day on which a change in the information provided in the registration application occurs. This form is designed for amending the Health Spa Registration Application to reflect a change in the total number of and amount paid for prepaid memberships. A certificate holder amending its Health Spa Registration Application to reflect a change in the total number of and amount paid for prepaid memberships is also responsible for any resulting changes to the amount of security required. Instructions for Form · Identifying Information: The certificate holder is the person who holds the health spa registration certificate. The certificate holder's name must match the name on the health spa registration application. The affiant is the person swearing to or affirming the contents of the Amended Statement Regarding Membership Totals and Cost. The health spa is the health spa for which the amended statement is being filed. · Statement: Enter the total number of all prepaid memberships and the total amount paid for all prepaid memberships. · Execution: The affiant must sign and date the notice before a notary public or other official who has authority to administer an oath. · Delivery Instructions: The form may be mailed to P.O. Box 13550, Austin, Texas 78711-3550 or delivered to the James Earl Rudder Office Building, 1019 Brazos, Austin, Texas 78701.
Revised 03/09

Form 3009

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Form #3009

Rev. 03/2009

This space reserved for office use

Submit to: SECRETARY OF STATE Statutory Documents Section P O Box 13550 Austin, TX 78711-3550 512-463-6906 512-475-2815 ­ Fax Filing Fee: None

AMENDED STATEMENT
REGARDING MEMBERSHIP
TOTALS AND COST


Identifying Information
Name of Certificate Holder (must match name on health spa registration application): Name of Affiant: Name of Health Spa: Location of Health Spa:
Street City State Zip

Statement
Affiant certifies that: The total number of all prepaid memberships at this health spa location is: The total amount paid for all of these prepaid memberships is:

$

Execution
Date:
Signature of Affiant

State of County of

) )

Printed or typed name of Affiant

Sworn to and subscribed before me this (seal)

day of
Notary Public Signature

, 20

.

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Form 3009

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