NEBRASKA SECRETARY OF STATE Business Services Division: Notary P. O. Box 95104 * Lincoln, NE 68509 (402)471-2558http://www.sos.ne.govEvidence of Employment in Nebraska Form This form must be completed for a non-resident applicant who is employed by a business located within the physical boundaries of Nebraska. The form must be completed by one of the officers, directors, managers, or authorized representatives of the business. being first duly sworn on oath say that , Name of Authorized Representative Name of Notary Applicant is employed as a(n) for , whose regular place of business Position of Notary Applicant Name of Business is located within the physical boundaries of Nebraska. The applicant is employed at the following location: Address of Business Signature of Authorized Representative Title of Authorized Representative Subscribed and sworn to before me this day of , 20 Signature of Notary Officer My Commission expires , 20 Affix Notary Seal Here American LegalNet, Inc. www.FormsWorkFlow.com