In the Matter of  the Negotiated Rulemaking                              )
Committee for
Application for
[Proposed Negotiated Rulemaking Committee]                )                                    membership
 NAC                )          on the committee.
 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.       The applicant represents the following identifiable interest which will be significantly affected by the
proposed administrative rule to be considered by the above-referenced negotiated rulemaking committee:

       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.              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):

         6.              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 to be considered by the above-referenced negotiated
rulemaking committee.

Submission of this
Application for Membership on the Committee 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.

Name of Nominating Party    

Full address of nominating party

Telephone Number of nominating party
  (including area code)