Application For Electronic Access Of Records - 2007

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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

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 #)