APPLICATION FOR REGISTRATION AS A FOREIGN PROFESSIONAL CORPORATION 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 9/25/06 Neb. Rev. Stat. 21-2209 American LegalNet, Inc. www.FormsWorkflow.com PERSONNEL RENDERING PROFESSIONAL SERVICES IN NEBRASKA (continued) ______________________________ Full Name & Nebraska License # ______________________________ Full Name & Nebraska License # ______________________________ Full Name & Nebraska License # ______________________________ Full Name & Nebraska License # ______________________________ Full Name & Nebraska License # ______________________________ Full Name & Nebraska License # ________________________________ 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 ________________________________ 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 ______________________________ Full Name, License # and State of License ______________________________ Full Name, License # and State of License ______________________________ Full Name, License # and State of License ______________________________ Full Name, License # and State of License ______________________________ Full Name, License # and State of License ________________________________ Director, Shareholder, Officer (list office held) ________________________________ Director, Shareholder, Officer (list office held) ________________________________ Director, Shareholder, Officer (list office held) ________________________________ Director, Shareholder, Officer (list office held) ________________________________ Director, Shareholder, Officer (list office held) ________________________________ Director, Shareholder, Officer (list office held) SIGNATURE OF OFFICER____________________________________Date_____________ NAME & TITLE OF OFFICER__________________________________________________ Please Print or Type American LegalNet, Inc. www.FormsWorkflow.com