Application For Electronic Access Of Records - 2007 Page 2
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1
2DIRECTORS
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___________________________________________________
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Parent category: Business