APPLICATION FOR REGISTRATION AS A
PROFESSIONAL LIMITED LIABILITY COMPANY
TO BE USED ONLY BY ENTITIES PROVIDING HEALTH RELATED
PROFESSIONAL SERVICES
John A. Gale, Secretary of State
Room 1301 State Capitol, P.O. Box 94608
Lincoln, NE 68509
Name of Limited Liability Company________________________________________
Principal Place of Business________________________________________________
Street Address
City
State
Zip
Practice of____________________________________________________________
Please name profession company is engaged in
Telephone Number (
) _______________________
_____ Check here if this is the first filing for a new professional limited liability company
MEMBERS OF THE LIMITED LIABILITY COMPANY
This Section Must be Completed. List all members of the limited liability company who are required
by Nebraska law to be licensed or certified to perform the professional services for which the limited
liability company 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
_____________________________________
____________________________________
Full Name & License #
Residence Street Address, City, State, Zip
_____________________________________
____________________________________
Full Name & License #
Residence Street Address, City, State, Zip
FILING FEE: $50.00
Revised 9/25/2006
Neb. Rev. Stat. 21-2631.01
(Please Complete Reverse Side)