Each foreign professional service corporation shall, at least once of each year on or before the date prescribed by the licensing authority, furnish a statement to the licensing authority listing the name and residence address of each shareholder, director, officer and corporate employee licensed by such licensing authority and certifying that such individuals intending to practice a profession which such foreign professional service corporation is authorized to practice in this state are licensed to practice said profession in this state. In the case of a foreign professional service corporation providing health services, such statement shall also certify that each shareholder, officer and director of the corporation is licensed to practice said profession in this state. The statement shall be signed by the president or any vice-president of the corporation and attested to by the secretary or any assistant secretary of the corporation.
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