Free APPLICATION FOR ELECTRONIC ACCESS OF RECORDS - Nebraska

APPLICATION FOR ELECTRONIC ACCESS OF RECORDS
TO BE USED ONLY BY ENTITIES PROVIDING HEALTH RELATED PROFESSIONAL SERVICES OR LICENSED BY THE BOARD OF ENGINEERS AND ARCHITECTS John A. Gale, Secretary of State Room 1301 State Capitol, P.O. Box 94608 Lincoln, NE 68509
http://www.sos.state.ne.us

Name of Corporation_____________________________________________________
(must be the exact name as designated in the articles of incorporation)

Principal Place of Business________________________________________________
Street Address City State Zip

Practice of____________________________________________________________
(Please name profession corporation is engaged in)

Telephone Number (

)________________________________________________

_____Check here if this is the first filing for a new professional corporation OFFICERS OF CORPORATION
This section must be completed. All officers of the corporation except secretary and asst. secretary must be licensed in Nebraska to render the professional service for which the professional corporation is organized.

______________________________
President (Full Name & License #)

________________________________
Residence Street Address, City, State, Zip

______________________________
Vice-President (Full Name & License #)

________________________________
Residence Street Address, City, State, Zip

______________________________
Secretary (Full Name & License #)

________________________________
Residence Street Address, City, State, Zip

______________________________
Asst. Secretary (Full Name & License #)

________________________________
Residence Street Address, City, State, Zip

______________________________
Treasurer (Full Name & License #)

________________________________
Residence Street Address, City, State, Zip

FEE: $50.00 (please complete reverse side)
Revised 5-08-2007 Neb. Rev. Stat. 21-2216

DIRECTORS This section must be completed. All directors must be licensed in Nebraska to practice in the profession for which the corporation was organized. (use additional sheets if needed) ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip

SHAREHOLDERS This section must be completed. All shareholders must be licensed in Nebraska to practice in the profession for which the corporation was organized. (use additional sheets if needed) ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip

PROFESSIONAL EMPLOYEES Professional employees must be licensed in Nebraska to practice the profession for which the corporation was organized, or, in a profession that is ancillary to such profession. List all employees of the corporation who are required by the State of Nebraska to be licensed or certified. Do not list officers, directors, or shareholders. (use additional sheets if needed) ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Full Name & License # ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip ____________________________________ Residence Street Address, City , State, Zip

SIGNATURE OF OFFICER______________________________________Date____________ NAME & TITLE OF OFFICER___________________________________________________ Please Print or Type