Amended Certificate Of Authority Application Form - 2011
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1APPLICATION FOR AMENDED
CERTIFICATE OF AUTHORITY
, Secretary of State
John A. Gale
Room 1301 State Capitol, P.O. Box 94608
Lincoln, NE 68509
Submit in Duplicate
Attach a certificate stating the name change amendment duly authenticated by the official having
custody of the corporate records in the state or country under whose law it is incorporated. Such
certificate shall not be more than 60 days old. A certified copy of the name change amendment
should not be submitted and is not acceptable in lieu of such certificate.
Name of Corporation_____________________________________________________
Incorporated under the laws of______________________________________________
Amended Name of Corporation_____________________________________________
Date Incorporation_________________, ______
Year
Period of Duration_________________
Address of Principal Office__________________________________________________
Zip
Street Address
City
State
Registered Agent________________________________________________________
Registered Office___________________________________________NE__________
Street Address and Post Office Box number (if any)
City
Zip
________________________
Effective date if other than 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.
Filing Fee: $30.00, plus $5.00 per page for attachments & for the certificate (if required).
Revised 12/2011
Neb. Rev. Stat. 21-20,171
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