APPLICATION FOR REGISTRATION AS A 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 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 #) ______________________________ Vice-President (Full Name & License #) ______________________________ Secretary (Full Name & License #) ______________________________ Asst. Secretary (Full Name & License #) ______________________________ Treasurer (Full Name & 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 FEE: $50.00 (please complete reverse side) Revised 9/25/06 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 OFFICER______________________________________Date____________ NAME & TITLE OF OFFICER___________________________________________________ Please Print or Type American LegalNet, Inc. www.FormsWorkflow.com