Application For Electronic Access Of Records For Limited Liability Companies - 2007
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1
2APPLICATION FOR ELECTRONIC ACCESS OF RECORDS
TO BE USED ONLY BY LIMITED LIABILITY COMPANIES PROVIDING
HEALTH RELATED PROFESSIONAL SERVICES OR LICENSED BY THE
BOARD OF ENGINEERS AND ARCHITECTS
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 (
) _______________________
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 5-08-07
Neb. Rev. Stat. 21-2631.01
(Please Complete Reverse Side)
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