Application For Electronic Access Of Records (Foreign Corporations) - 2010
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1
2APPLICATION FOR ELECTRONIC ACCESS OF
RECORDS
(FOREIGN CORPORATIONS)
TO BE USED ONLY BY ENTITIES 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 Corporation_____________________________________________________
(must be the exact name as registered with the Nebraska Secretary of State)
Principal Place of Business________________________________________________
Street Address
City
State
Zip
Practice of____________________________________________________________
(Please name profession corporation is engaged in)
Telephone Number (
)________________________________________________
_____Check here if this is the first filing for a new foreign professional corporation
PERSONNEL OF THE CORPORATION WHO WILL BE RENDERING
PROFESSIONAL SERVICES IN NEBRASKA AND/OR ARE
LICENSED IN NEBRASKA
______________________________
________________________________
Full Name & Nebraska License #
Residence Street Address, City, State, Zip
______________________________
________________________________
Full Name & Nebraska License #
Residence Street Address, City, State, Zip
______________________________
________________________________
Full Name & Nebraska License #
Residence Street Address, City, State, Zip
______________________________
________________________________
Full Name & Nebraska License #
Residence Street Address, City, State, Zip
______________________________
________________________________
Full Name & Nebraska License #
Residence Street Address, City, State, Zip
______________________________
________________________________
Full Name & Nebraska License #
Residence Street Address, City, State, Zip
FEE: $50.00
(please complete reverse side)
Revised 10-2010
Neb. Rev. Stat. 21-2209
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