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Application For Registration As Foreign Professional Corporation - Nebraska

Application For Registration As Foreign Professional Corporation Form. This is a Nebraska form and can be used in Corporation Secretary Of State .
 Fillable pdf Last Modified 1/30/2007
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APPLICATION FOR REGISTRATION AS A FOREIGN PROFESSIONAL CORPORATION (Registration must be renewed annually) TO BE USED ONLY BY ENTITIES PROVIDING HEALTH RELATED PROFESSIONAL SERVICES John A. Gale, Secretary of State Room 1301 State Capitol, P.O. Box 94608 Lincoln, NE 68509 http://www.sos.state.ne.us Name of Corporation_____________________________________________________ (must be the exact name as designated in the articles of incorporation) 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 8/22/2001 Neb. Rev. Stat. 21-2209 <<<<<<<<<********>>>>>>>>>>>>> 2 PERSONNEL RENDERING PROFESSIONAL SERVICES IN NEBRASKA (continued) ______________________________ ________________________________ 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 OFFICERS SHAREHOLDERS AND DIRECTORS OF THE CORPORATION WHO ARE NOT LICENSED IN NEBRASKA ______________________________ ________________________________ Full Name, License # and State of License Director, Shareholder, Officer (list office held) ______________________________ ________________________________ Full Name, License # and State of License Director, Shareholder, Officer (list office held) ______________________________ ________________________________ Full Name, License # and State of License Director, Shareholder, Officer (list office held) ______________________________ ________________________________ Full Name, License # and State of License Director, Shareholder, Officer (list office held) ______________________________ ________________________________ Full Name, License # and State of License Director, Shareholder, Officer (list office held) ______________________________ ________________________________ Full Name, License # and State of License Director, Shareholder, Officer (list office held) SIGNATURE OF OFFICER____________________________________Date_____________ NAME & TITLE OF OFFICER__________________________________________________ Please Print or Type
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