Application For Electronic Access Of Records

APPLICATION 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 , Secretary of State P.O. Box 94608 Lincoln, NE 68509 www.sos.ne.gov Name of Limited Liability Company Practice of (the professional service for which the limited liability company is organized to do business) 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 (attach additional pages 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 (over) American LegalNet, Inc. www.FormsWorkFlow.com MANAGERS OF THE LIMITED LIABILITY COMPANY This Section Must be Completed. List all managers 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 (attach additional pages 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 PROFESSIONAL EMPLOYEES OF THE LIMITED LIABILITY COMPANY This Section Must be Completed. List all professional employees 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 (attach additional pages if needed). Residence Street Address, City, State, Zip Residence Street Address, City, State, Zip Residence Street Address, City, State, Zip Residence Street Address, City, State, Zip Residence Street Address, City, State, Zip Date Full Name & License # Full Name & License # Full Name & License # Full Name & License # Full Name & License # Signature of Authorized Representative Printed Name of Authorized Representative FILING FEE: $50.00 Revised Neb. Rev. Stat. 247 21-186 American LegalNet, Inc. www.FormsWorkFlow.com