Fill and Sign the Free Nebraska Application for Certificate of Authority to Form

APPLICATION FOR REGISTRATION AS A PROFESSIONAL CORPORATION TO BE USED ONLY BY ENTITIES PROVIDING HEALTH RELATED PROFESSIONAL SERVICES John A. Gale, Secretary of State Room 130 1 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 Pl ace of Business________________________________________________ Street Address City State Zip Practice of_______________________________ _____________________________ (Please name pr ofession corporation is engaged in) Telephone Number ( )_________________ _______________________________ _____Check here if this is the first filing for a new professional corpo\ ration 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 whic\ h 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, Zi p ______________________________ ________________________________ Secretary (Full Name & License #) Residence Street Address, City, State, Zip ______________________________ ________________________________ Asst. Secretary (Ful l 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 9/25/06 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 # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # 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 # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # 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 # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # Residence Street Address, City , State, Zip ____________________________________ ____________________________________ Full Name & License # Residence Street Address, City , State, Zip SIGNATURE OF OFFICER______________________________________Date____________ NAME & TITLE OF OFFICER___________________________________________________ Please Print or Type