Free APPLICATION FOR ELECTRONIC ACCESS OF RECORDS - Nebraska

APPLICATION FOR ELECTRONIC ACCESS OF RECORDS (FOREIGN CORPORATIONS)
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 foreign professional corporation
PERSONNEL OF THE CORPORATION WHO WILL BE RENDERING PROFESSIONAL SERVICES IN NEBRASKA AND/OR ARE LICENSED IN NEBRASKA

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

FEE: $50.00 (please complete reverse side)
Revised 5-08-07 Neb. Rev. Stat. 21-2209

PERSONNEL RENDERING PROFESSIONAL SERVICES IN NEBRASKA (continued)

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

______________________________
Full Name & Nebraska License #

________________________________
Residence Street Address, City, State, Zip

OFFICERS SHAREHOLDERS AND DIRECTORS OF THE CORPORATION WHO ARE NOT LICENSED IN NEBRASKA

______________________________
Full Name, License # and State of License

________________________________
Director, Shareholder, Officer (list office held)

______________________________
Full Name, License # and State of License

________________________________
Director, Shareholder, Officer (list office held)

______________________________
Full Name, License # and State of License

________________________________
Director, Shareholder, Officer (list office held)

______________________________
Full Name, License # and State of License

________________________________
Director, Shareholder, Officer (list office held)

______________________________
Full Name, License # and State of License

________________________________
Director, Shareholder, Officer (list office held)

______________________________
Full Name, License # and State of License

________________________________
Director, Shareholder, Officer (list office held)

SIGNATURE OF OFFICER____________________________________Date_____________ NAME & TITLE OF OFFICER__________________________________________________ Please Print or Type