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Application For Liquor License LCC 102 - Nebraska
| Application For Liquor License LCC Form. This is a Nebraska form and can be used in Liquor Control Commission Statewide . |
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APPLICATION FOR LIQUOR LICENSE LIMITED LIABILITY COMPANY (LLC) INSERT - FORM 3b NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 Website: www.lcc.ne.gov Office Use All members including spouse(s), are required to adhere to the following requirements: 1) All members spouse(s) must be listed 2) Managing/Contact member and all members holding over 25% interest and their spouse(s) (if applicable) must submit fingerprints (2 cards per person) 3) Managing/Contact member and all members holding over 25 % shares of stock and their spouse (if applicable) must sign the signature page of the Application for License form 100 (even if a spousal affidavit has been submitted) Attach copy of Articles of Organization (Articles must show barcode receipt by Secretary of States office) Name of Registered Agent:____________________________________________________________________ Name of Limited Liability Company that will hold license as listed on the Articles of Organization __________________________________________________________________________________________ LLC Address:______________________________________________________________________________ City:_______________________________________ State:_______________ Zip Code:__________________ LLC Phone Number: ______________________________LLC Fax Number____________________________ Name of Managing/Contact Member Name and information of contact member must be listed on following page Last Name:___________________________________ First Name:______________________ MI:__________ Home Address:___________________________________________ City:______________________________ State:________________ Zip Code:________________ Home Phone Number:__________________________ __________________________________________________________________________________________ Signature of Managing/Contact Member ACKNOWLEDGEMENT State of Nebraska County of ____________________________________________ The foregoing instrument was acknowledged before me this _____________________________________________________ by ______________________________________________________ Date name of person acknowledge ____________________________________________________ Affix Seal FORM 102 REV 12/2010 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com List names of all members and their spouses (even if a spousal affidavit has been submitted) Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ FORM 102 REV 12/2010 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com List names of all members and their spouses (even if a spousal affidavit has been submitted) Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ FORM 102 REV 12/2010 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Is the applying Limited Liability Company controlled by another corporation/company? YES NO If yes, provide the following: 1) Name of corporation ____________________________________________________________ 2) Supply an organizational chart of the controlling corporation named above 3) Controlling corporation MUST be registered with the Nebraska Secretary of State, copy of articles mu
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