Application For Electronic Access Of Records

APPLICATION FOR ELECTRONIC ACCESS OF RECORDS TO BE USED ONLY BY ENTITIES PROVIDING HEALTH RELATED PROFESSIONAL SERVICES OR LICENSED BY THE BOARD OF ENGINEERS AND ARCHITECTS , Secretary of State P.O. Box 94608 Lincoln, NE 68509 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 professional corporation OFFICERS OF CORPORATION This section must be completed. All officers of the corporation except secretary and asst. secretary must be licensed in Nebraska to render the professional service for which the professional corporation is organized. President (Full Name & License #) Residence Street Address, City, State, Zip Vice-President (Full Name & License #) Residence Street Address, City, State, Zip Secretary (Full Name & License #) Residence Street Address, City, State, Zip Asst. Secretary (Full Name & License #) Residence Street Address, City, State, Zip Treasurer (Full Name & License #) Residence Street Address, City, State, Zip FEE: $50.00(please complete reverse side) Revised Neb. Rev. Stat. 21-2216 American LegalNet, Inc. www.FormsWorkFlow.com DIRECTORS This section must be completed. All directors must be licensed in Nebraska to practice in the profession for which the corporation 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 SHAREHOLDERS This section must be completed. All shareholders must be licensed in Nebraska to practice in the profession for which the corporation 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 PROFESSIONAL EMPLOYEES Professional employees must be licensed in Nebraska to practice the profession for which the corporation was organized, or , in a profession that is ancillary to such profession. List all employees of the corporation who are required by the State of Nebraska to be licensed or certified. Do not list officers, directors, or shareholders. (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 SIGNATURE OF OFFICERDate NAME & TITLE OF OFFICER Please Print or Type American LegalNet, Inc. www.FormsWorkFlow.com