Application For Registration As A Professional Corporation - Nebraska Real Estate Commission - 2015 Page 2
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2SHAREHOLDERS
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 # (if applicable)
Residence - Street Address, City, State, Zip
______________________________________________
____________________________________________
Full Name & License # (if applicable)
Residence - Street Address, City, State, Zip
______________________________________________
______________________________________________
Full Name & License # (if applicable)
Residence - Street Address, City, State, Zip
______________________________________________
______________________________________________
Full Name & License # (if applicable)
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. Do Not list officers, directors or shareholders. (Use additional sheets if needed)
_______________________________________
______________________________________
Full Name & License # (if applicable)
Residence - Street Address, City, State, Zip
_______________________________________
______________________________________
Full Name & License # (if applicable)
Residence - Street Address, City, State, Zip
_______________________________________
______________________________________
Full Name & License # (if applicable)
Residence - Street Address, City, State, Zip
_______________________________________
______________________________________
Full Name & License # (if applicable)
Residence - Street Address, City, State, Zip
Submission of this Application for Registration as a Professional Corporation verifies that all statements and
information provided herein are true and correct and may be used as necessary by the Nebraska Real
Estate Commission if furtherance of assuring compliance with the laws it regulates.
DATE ______________________________
SIGNATURE OF OFFICER:___________________________________________________
NAME & TITLE OF OFFICER:____________________________________________________
Please Print or Type
CREDIT CARD PAYMENT OPTION: REMINDER - FEES ARE NOT REFUNDABLE
(Please note: debit cards are not accepted)
_____
Please charge my credit card for only this transaction.
_____VISA
_____MasterCard
_____Discover
Credit Card Number__________________________________________________
Card Expiration Date:
Month ___________ Year ___________
Cardmember's Signature_______________________________________________
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