Application For Certificate Of Authority To Transact Business
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1
2APPLICATION FOR CERTIFICATE
OF AUTHORITY TO TRANSACT BUSINESS
(Non-Profit Corporations)
, 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)
*
Include a resolution from the Board of Directors signed by the Secretary adopting this fictitious name
Incorporated under the laws of______________________________________________
Date Incorporation_________________, _____ Period of Duration________________
Year
Corporate Type (check one) ____ Public Benefit ____ Mutual Benefit ____ Religious
Does the Corporation Have Members? ____ Yes ____ No
Address of Principal Office________________________________________________
Street Address
City
State
Zip
Registered Agent________________________________________________________
Registered Office_____________________________________________NE________
Street Address and Post Office Box (if any)
City
Zip
Effective date if other than the date filed ___________
_________________________________
________________________________
Signature
Printed Name/Title
NOTE: Every filing must 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 filing you must provide a list of officers and directors names and
street addresses.
FILING FEE: $25.00
(please add $5.00 a page for each additional page)
Revised 12/2011
Neb. Rev. Stat. 21-19,148
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