for the renewal of its certificate under Section 12 of this Act, such corporation shall also file with the appropriate regulating authority a certificate giving the name and residence addresses of all shareholders as of the last day of the month preceding such filing, and certifying that all such shareholders are duly licensed to render the same professional services or related professional services as those for which the corporation was organized. This certificate shall be made on a form prescribed and furnished by the appropriate regulating authority, shall be signed by the president or vice-president and attested by the secretary or assistant secretary of the professional corporation, and acknowledged and sworn to before a notary public by the persons executing the certificate.
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