Fillable APPLICATION FOR ELECTRONIC ACCESS OF RECORDS (How to Start a Business)

Fill Online, Printable, Fillable, Blank APPLICATION FOR ELECTRONIC ACCESS OF RECORDS (How to Start a Business) Form

Use Fill to complete blank online HOW TO START A BUSINESS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

APPLICATION FOR ELECTRONIC ACCESS OF RECORDS (How to Start a Business)

On average this form takes 9 minutes to complete

The APPLICATION FOR ELECTRONIC ACCESS OF RECORDS (How to Start a Business) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your How to Start a Business forms online.

BROWSE HOW TO START A BUSINESS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
APPLICATION FOR ELECTRONIC ACCESS OF RECORDS
TO BE USED ONLY BY LIMITED LIABILITY COMPANIES PROVIDING
HEALTH RELATED PROFESSIONAL SERVICES OR LICENSED BY THE
BOARD OF ENGINEERS AND ARCHITECTS
John A. Gale, Secretary of State
Room 1301 State Capitol, P.O. Box 94608
Lincoln, NE 68509
http://www.sos.ne.gov
Name of Limited Liability Company_________________________________________
Practice of_____________________________________________________________
(the professional service for which the limited liability company is organized to do business)
MEMBERS OF THE LIMITED LIABILITY COMPANY
This Section Must be Completed. List all members of the limited liability company who are
required by Nebraska law to be licensed or certified to perform the professional services for
which the limited liability company was organized (attach additional pages 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
_____________________________________ ____________________________________
Full Name & License # Residence Street Address, City, State, Zip
(over)
MANAGERS OF THE LIMITED LIABILITY COMPANY
This Section Must be Completed. List all managers of the limited liability company who are
required by Nebraska law to be licensed or certified to perform the professional services for
which the limited liability company was organized (attach additional pages 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
_____________________________________ ____________________________________
Full Name & License # Residence Street Address, City, State, Zip
PROFESSIONAL EMPLOYEES OF THE LIMITED LIABILITY COMPANY
This Section Must be Completed. List all professional employees of the limited liability
company who are required by Nebraska law to be licensed or certified to perform the
professional services for which the limited liability company was organized (attach additional
pages 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
_____________________________________ ____________________________________
Full Name & License # Residence Street Address, City, State, Zip
____________________________________ ____________________________________
Signature of Authorized Representative Date
______________________________________
Printed Name of Authorized Representative
FILING FEE: $50.00
Revised Jan. 2013 Neb. Rev. Stat. § 21-186
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

APPLICATION FOR ELECTRONIC ACCESS OF RECORDS (How to Start a Business)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document