Application For Certificate Of Authority To Transact Business Form

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APPLICATION FOR CERTIFICATE OF AUTHORITY
TO TRANSACT BUSINESS
, Secretary of State
John A. Gale
Room 1301 State Capitol, P.O. Box 94608
Lincoln, NE 68509
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 unavailable for use or does not comply with Nebraska law)
Incorporated under the laws of______________________________________________
Date Incorporation__________________________, _______
Year
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
________________________
_________________________________
DATED
Signature
_________________________________
Printed Name/Title
NOTE: The Business Corporation Act requires that every 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, the 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 form, you must list officers and directors on back
FILING FEE: $145.00 (if you have more than one page listing officers and directors
please add $5.00 a page for each additional page)
Revised 12/30/2008
Neb. Rev. Stat. 21-20,170

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