APPLICATION FOR CERTIFICATE OF AUTHORITY TO TRANSACT BUSINESS (Non-Profit Corporations) John A. Gale, Secretary of State Room 1301 State Capitol, P.O. Box 94608 Lincoln, NE 68509 http://www.sos.state.ne.us Submit in Duplicate Attach a certificate of good standing duly authenticated by the official having custody of the corporate records in the state or country under whose law the corporation is incorporated. Such certificate shall not be more than 60 days old. A certified copy of the articles of incorporation should not be submitted and is not acceptable in lieu of such certificate. Name of Corporation_____________________________________________________ Fictitious Name of Corporation_____________________________________________ (to be used only if actual corporate name is unavailable for use or does not comply with Nebraska law) Incorporated under the laws of______________________________________________ Date Incorporation_________________, _____ Period of Duration________________ Year Corporate Type (check one) ____ Public Benefit ____ Mutual Benefit ____ Religious Does the Corporation Have Members? ____ Yes ____ No Address of Principal Office________________________________________________ Street Address City State Zip Registered Agent________________________________________________________ Registered Office_____________________________________________NE________ Street Address and Post Office Box (if any) DATED____________________ City Zip _________________________________ 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. NOTE: To complete this filing you must provide a list of officers and directors names and street addresses. FILING FEE: $25.00 (if you have more than one page listing officers and directors please add $5.00 a page for each additional page) Revised August 2010 Neb. Rev. Stat. 21-19,148 American LegalNet, Inc. www.FormsWorkFlow.com OFFICERS: DIRECTORS: _________________________________________ Name/Title ________________________________________ Name _________________________________________ Street Address ________________________________________ Street Address _________________________________________ City State Zip ________________________________________ City State Zip _________________________________________ Name/Title ________________________________________ Name _________________________________________ Street Address ________________________________________ Street Address _________________________________________ City State Zip ________________________________________ City State Zip _________________________________________ Name/Title ________________________________________ Name _________________________________________ Street Address ________________________________________ Street Address _________________________________________ City State Zip ________________________________________ City State Zip _________________________________________ Name/Title ________________________________________ Name _________________________________________ Street Address ________________________________________ Street Address _________________________________________ City State Zip ________________________________________ City State Zip _________________________________________ Name/Title ________________________________________ Name _________________________________________ Street Address ________________________________________ Street Address _________________________________________ City State Zip ________________________________________ City State Zip _________________________________________ Name/Title ________________________________________ Name _________________________________________ Street Address ________________________________________ Street Address _________________________________________ City State Zip ________________________________________ City State Zip _________________________________________ Name/Title ________________________________________ Name _________________________________________ Street Address ________________________________________ Street Address _________________________________________ City State Zip ________________________________________ City State Zip Please Copy this page and submit additional pages if needed. American LegalNet, Inc. www.FormsWorkFlow.com