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

_________________________________ _________________________________ APPLICATION FOR CERTIFICATE OF AUTHORITY TO TRANSACT BUSINESS John A. Gale , Secretary of State Room 1301 State Capitol, P.O. Box 94608 Lincoln, NE 68509 http://www.sos.state.ne.us Submit in Duplicate Attach a certificate of good standing duly authenticated by the official having custody of the corporate records in the state or country under whose law the corporation is incorporated. Such certificate shall not be more than 60 days old. A certified copy of the articles of incorporation should not be submitted and is not acceptable in lieu of such certificate. Name of Corporation_____________________________________________________ Fictitious Name of Corporation*_____________________________________________ (to be used only if actual corporate name is unavaila ble for use or does not comply with Nebraska law) *Must provide a resolution from the Board of Directors signed by the Secretary adopting this fictitious name. Note: Fictitious name must contain one of the words incorporated, corporation, limited or an abbreviation thereof. Incorporated under the laws of______________________________________________ Date of Incorporation__________________ Period of Duration___________________ Address of Principal Office________________________________________________ Street Address City State Zip Registered Agent________________________________________________________ Registered Office_____________________________________________NE________ Street Address and Post Office Box (if any) City Zip Effective date if other than the date filed ________________ Signature Printed Name/Title NOTE: The Business Corporation Act requires that ever y filing be signed by the chairperson of the board of directors, the president, or one of the officers of the corporation. If the corporation has not yet been formed or directors have not yet been selected, th e filing shall be signed by an incorporator . If the corporation is in the hands of a receiver, trustee, or other court appointed fiduciary , the filing shall be signed by that fiduciary. NOTE: To complete this filing you must provide a list of officers and directors names and street addresses . FILING FEE: $145.00 (please add $5.00 a page for each additional page) Revised 12/2011 Neb. Rev. Stat. 21-20,17 0 _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ OFFICERS: DIRECTORS: Name/Title Name Street Address Street Address City State Zi p City State Zip Name/Title Name Street Address Street Address City State Z ip City State Zip Name/Title Name Street Address Street Address City State Zip City State Zip Name/Title Name Street Address Street Address City State Zi p City State Zip Name/Title Name Street Address Street Address City State Zi p City State Zip Name/Title Name Street Address Street Address City State Zip City State Zip Please Copy this page and submit additional pages if needed.