BEFORE THE STATE REAL ESTATE COMMISSION
STATE OF NEBRASKA

In the Matter of  the Negotiated Rulemaking                              )                                 Application for
Committee for
          )                  membership
[Proposed Negotiated Rulemaking Committee]                  )                               on the Committee
 
NAC                )     (interest inadequately represented)
 
Title Number                         Chapter-Section

        1.        The undersigned person (the applicant) hereby applies for membership on the above-referenced
negotiated rulemaking committee proposed by the Commission.

                                 
                          
Name of applicant
                                 

                          
Full address of applicant
                                 

                                   
Applicant's telephone number (including area code)

         2

       3.            The applicant is authorized to represent parties related to the interest listed above because:

         4.              The applicant can adequately represent the parties and interest listed above because:               
                 

         5.             Reasons that persons already serving on the above-referenced negotiated rulemaking committee do not 
adequately represent the interest listed in paragraph 2 above include:
          

      6.             In support of his or her application, the applicant will submit, within five days from submitting this form, 
the following documents to this petition (list all documents to be submitted):
          

         7.             By submitting this application, the applicant hereby certifies that he or she will  represent the interest identified
above to the best of his or her ability in the negotiation process, and that he or she is willing to actively negotiate in good
faith to reach a consensus on the proposed rule being considered by the above-referenced negotiated rulemaking committee.          

Submission of this Application for Membership on the Committee (interest inadequately represented) verifies that all statements and information provided herein are true and correct and may be used as necessary by the Nebraska Real Estate Commission if furtherance of assuring compliance with the laws it regulates.

 Dated               
                                                   Name of Applicant