APPLICATION FOR ELECTRONIC ACCESS OF RECORDS (FOREIGN CORPORATIONS) TO BE USED ONLY BY ENTITIES PROVIDING HEALTH RELATED 002PROFESSIONAL SERVICES OR LICENSED BY THE BOARD OF ENGINEERS AND ARCHITECTS 002, Secretary of State P.O. Box 94608 Lincoln, NE 68509 002www.sos.ne002Name of Corporation (must be the exact name as registered with the Nebraska Secretary of State) 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 002LICENSED IN NEBRASKA 002Full 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 Neb. Rev. Stat. 21-2209002 American LegalNet, Inc. www.FormsWorkFlow.com PERSONNEL RENDERING PROFESSIONAL SERVICES IN NEBRASKA (continued) Full Name & Nebraska License # Residence Street Address, City, State, Zip002 Full Name & Nebraska License # Residence Street Address, City, State, Zip002 Full Name & Nebraska License # Residence Street Address, City, State, Zip002 Full Name & Nebraska License # Residence Street Address, City, State, Zip002 Full Name & Nebraska License # Residence Street Address, City, State, Zip002 Full Name & Nebraska License # Residence Street Address, City, State, Zip002 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 OFFICERDate NAME & TITLE OF OFFICER Please Print or Type American LegalNet, Inc. www.FormsWorkFlow.com