PROFESSIONAL LIMITED LIABILITY COMPANY

FOR THE PRACTICE OF DENTISTRY

1. The attached application to form a P. L. L. C. shall be completed.

2. Only duly licensed dentists shall form or become incorporators for a P. L. L. C. for dentistry.

3. All P. L. L. C. for the practice of dentistry shall use surnames of licensed dentists only. (ie. Dr. John B. Doe, P. L. L. C.; Dr. John B. Doe, Professional L. L. C.; Drs. Doe and Smith, P. L. L. C.; or Drs. Doe and Smith, Professional L. L. C.)
DO NOT ADD DESCRIPTIVE WORDS IF APPROVAL IS DESIRED.

4. All applications to form a P. L. L. C. shall have two copies of the Articles of Organization attached.

5. Fee of $200.00 payable to the West Virginia Board of Dental Examiners must accompany application.

6. Annually, each P. L. L. C. shall register on a form provided by the West Virginia Board of Dental Examiners and pay an annual registration fee of $150.00. 

7. The insurance necessary for a professional limited liability company is $1,000,000.00 for the company (not for each dentist). Proof of this coverage must be submitted with your application.

8. All Articles of Organization for P. L. L. C. for the practice of dentistry shall contain within the purpose clause: ASaid P. L. L. C. will abide by the laws of the State of West Virginia, more specifically, Chapter 31B, Article 13 et. seq. and Chapter 30, Article 4, Sections 1 and 4 et. seq.

APPLICATION TO FORM P. L. L. C. FOR THE PRACTICE OF DENTISTRY

NAME OR NAMES OF DULY WEST VIRGINIA DATE
LICENSED DENTISTS LICENSE NO. ISSUED

(1)

(2)

(3)

(4)

(5)

If there are more than five applicants, please use reverse side of application.

The above named applicants hereby certify that they are duly licensed to practice dentistry in the State of West Virginia and desire to form a P. L. L. C. for the practice of dentistry.

(Above personal signatures of applicants are to be certified by a notary public.)

Taken, subscribed, and sworn to before the undersigned this day of
, 20 .
My commission expires .

NOTARY PUBLIC

Two original copies of the Articles of Organization shall be attached to and made a part of this application. Further, please enclose a check or money order in the amount of $200.00 payable to the West Virginia Board of Dental Examiners, no part of which is refundable. Also enclose the check made payable to the Secretary of State=s office unless it has already been paid to the Secretary of State. Please return application and necessary papers to Susan Combs, Administrative Secretary, West Virginia Board of Dental Examiners, 1319 Robert C. Byrd Drive, PO Box 1447, Crab Orchard, WV 25827.