Free APPLICATION FOR ELECTRONIC ACCESS OF RECORDS - Nebraska

APPLICATION FOR ELECTRONIC ACCESS OF RECORDS
TO BE USED ONLY BY LIMITED LIABILITY COMPANIES 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 Limited Liability Company_________________________________________ Principal Place of Business________________________________________________
Street Address City State Zip

Practice of_____________________________________________________________
Please name profession company is engaged in

Telephone Number (

) _______________________

MEMBERS OF THE LIMITED LIABILITY COMPANY
This Section Must be Completed. List all members of the limited liability company who are required by Nebraska law to be licensed or certified to perform the professional services for which the limited liability company was organized. (use additional sheets if needed) _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ 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 ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip

FILING FEE: $50.00
Revised 5-08-07 Neb. Rev. Stat. 21-2631.01

(Please Complete Reverse Side)

MANAGERS OF THE LIMITED LIABILITY COMPANY
This Section Must be Completed. List all managers of the limited liability company who are required by Nebraska law to be licensed or certified to perform the professional services for which the limited liability company was organized. (use additional sheets if needed) _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ 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 ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip

PROFESSIONAL EMPLOYEES OF THE LIMITED LIABILITY COMPANY
This Section Must be Completed. List all professional employees of the limited liability company who are required by Nebraska law to be licensed or certified to perform the professional services for which the limited liability company was organized. (use additional sheets if needed) _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ 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 ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip

_____________________________________
Signature of Member

____________________________________ or Signature of Manager ______________________Date or
Printed Name of Manager

________________________Date
Printed Name of Member

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