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SELECT-A-FORM INC.

Company Details

Name: SELECT-A-FORM INC.
Jurisdiction: New York
Legal type: DOMESTIC BUSINESS CORPORATION
Status: Active
Date of registration: 14 Aug 1985 (39 years ago)
Entity Number: 1018491
County: Suffolk
Place of Formation: New York
Address: 4717 VETERANS MEMORIAL HIGHWAY, HOLBROOK, NY, United States, 11741
Address ZIP Code: 11741

Shares Details

Shares issued 200

Share Par Value 0

Type NO PAR VALUE

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
SELECT A FORM INC 401(K) PROFIT SHARING PLAN & TRUST 2015 112771584 2017-08-31 SELECT A FORM INC 29
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-01-01
Business code 323100
Sponsor’s telephone number 6319813076
Plan sponsor’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 117414515

Signature of
Role Plan administrator
Date 2017-08-31
Name of individual signing DAVID WALTERS
Role Employer/plan sponsor
Date 2017-08-31
Name of individual signing DAVID WALTERS
SELECT-A-FORM INC 401 K PROFIT SHARING PLAN TRUST 2014 112771584 2015-05-28 SELECT A FORM INC 28
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-01-01
Business code 323100
Sponsor’s telephone number 6319813076
Plan sponsor’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 117414515

Signature of
Role Plan administrator
Date 2015-05-28
Name of individual signing JULIA FARRELL
SELECT-A-FORM INC 401 K PROFIT SHARING PLAN TRUST 2013 112771584 2014-05-06 SELECT A FORM INC 25
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-01-01
Business code 323100
Sponsor’s telephone number 6319813076
Plan sponsor’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 117414515

Signature of
Role Plan administrator
Date 2014-05-06
Name of individual signing JULIA FARRELL
SELECT-A-FORM INC 401 K PROFIT SHARING PLAN TRUST 2012 112771584 2013-06-06 SELECT A FORM INC 27
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-01-01
Business code 323100
Sponsor’s telephone number 6319813076
Plan sponsor’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 117414515

Signature of
Role Plan administrator
Date 2013-06-06
Name of individual signing SELECT A FORM INC
SELECT-A-FORM INC 401 K PROFIT SHARING PLAN TRUST 2011 112771584 2012-05-17 SELECT A FORM INC 26
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-01-01
Business code 323100
Sponsor’s telephone number 6319813076
Plan sponsor’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 117414515

Plan administrator’s name and address
Administrator’s EIN 112771584
Plan administrator’s name SELECT A FORM INC
Plan administrator’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 117414515
Administrator’s telephone number 6319813076

Signature of
Role Plan administrator
Date 2012-05-17
Name of individual signing SELECT A FORM INC
SELECT-A-FORM INC 401 K PROFIT SHARING PLAN TRUST 2010 112771584 2011-05-03 SELECT A FORM INC 27
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-01-01
Business code 323100
Sponsor’s telephone number 6319813076
Plan sponsor’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 11741

Plan administrator’s name and address
Administrator’s EIN 112771584
Plan administrator’s name SELECT A FORM INC
Plan administrator’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 11741
Administrator’s telephone number 6319813076

Signature of
Role Plan administrator
Date 2011-05-03
Name of individual signing SELECT A FORM INC
SELECT-A-FORM INC 2009 112771584 2010-07-22 SELECT A FORM INC 31
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-01-01
Business code 323100
Sponsor’s telephone number 6319813076
Plan sponsor’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 11741

Plan administrator’s name and address
Administrator’s EIN 112771584
Plan administrator’s name SELECT A FORM INC
Plan administrator’s address 4717 VETERANS MEMORIAL HWY, HOLBROOK, NY, 11741
Administrator’s telephone number 6319813076

Signature of
Role Plan administrator
Date 2010-07-22
Name of individual signing SELECT A FORM INC

Chief Executive Officer

Name Role Address
DAVID WALTERS Chief Executive Officer 4717 VETERANS MEMORIAL HIGHWAY, HOLBROOK, NY, United States, 11741

DOS Process Agent

Name Role Address
DAVID WALTERS DOS Process Agent 4717 VETERANS MEMORIAL HIGHWAY, HOLBROOK, NY, United States, 11741

History

Start date End date Type Value
1985-08-14 1993-04-06 Address 641 1ST ST, RONKONKOMA, NY, 11779, USA (Type of address: Service of Process)

Filings

Filing Number Date Filed Type Effective Date
130823002109 2013-08-23 BIENNIAL STATEMENT 2013-08-01
110823002345 2011-08-23 BIENNIAL STATEMENT 2011-08-01
090811002520 2009-08-11 BIENNIAL STATEMENT 2009-08-01
070813003400 2007-08-13 BIENNIAL STATEMENT 2007-08-01
051014002310 2005-10-14 BIENNIAL STATEMENT 2005-08-01
030819002361 2003-08-19 BIENNIAL STATEMENT 2003-08-01
010809002292 2001-08-09 BIENNIAL STATEMENT 2001-08-01
991213002316 1999-12-13 BIENNIAL STATEMENT 1999-08-01
930922002151 1993-09-22 BIENNIAL STATEMENT 1993-08-01
930406002085 1993-04-06 BIENNIAL STATEMENT 1992-08-01

Related by officers

DAVID WALTERS

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Related by address

No related companies by address

Date of last update: 28 Oct 2024

Sources: New York Secretary of State

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