Nebraska > Statewide > Liquor Control Commission
Manager Application 103 - Nebraska
| Manager Application Form. This is a Nebraska form and can be used in Liquor Control Commission Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
MANAGER APPLICATION INSERT - FORM 3c 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 Manager must: · Complete all sections of the application make sure it is signed by a corporate officer* *corporate officer must be an individual on file with the Liquor Control Commission · Include two signed, completed fingerprint cards with a check for $38 payable to the NE State Patrol (unless you have fingerprints on file with us that are less than two years old, you must indicate that on the application) Provide a copy of one of the following: US birth certificate, naturalization papers or US passport (even if you have provided this before) Be a registered voter in the State of Nebraska · · Spouse who will not participate in the business, spouse must: · Sign the application · · Complete the Spousal Affidavit of Non Participation Insert (must be notarized). The nonparticipating spouse completes the top half, the manager completes the bottom half Need not answer question #1 of the application Spouse who will participate in the business, the spouse must: · Sign the application · Include two signed, completed fingerprint cards with a check for $38 payable to the NE State Patrol (unless you have fingerprints on file with us that are less than two years old, you must indicate this on the application) Provide a copy of one of the following: birth certificate, naturalization papers or US passport (even if you have provided this before) Be a registered voter in the state of Nebraska Spousal Affidavit of Non Participation Insert not required · · · Form 103 Rev 11/2012 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com MANAGER APPLICATION INSERT - FORM 3c 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 Corporate manager, including their spouse, are required to adhere to the following requirements 1) Must be a citizen of the United States 2) Must be a Nebraska resident (Chapter 2 006) and must provide proof of voter registration in the State of Nebraska 3) Must provide a copy of one of the following: state issued US birth certificate, naturalization paper or US passport 4) Must submit fingerprints (unless a non-participating spouse) (2 cards per person) and fees of $38 per person, made payable to Nebraska State Patrol 5) Must be 21 years of age or older 6) May be required to take a training course Corporation/LLC information Name of Corporation/LLC:_________________________________________________________________ Premise information Premise License Number:__________________________________________________________________ (if new application leave blank) Premise Trade Name/DBA:_________________________________________________________________ Premise Street Address:____________________________________________________________________ City:________________________________State:___________________Zip Code:____________________ Premise Phone Number:____________________________________________________________________ The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b or listed with the Commission. Click on this link to see authorized individuals. http://www.lcc.ne.gov/license_search/licsearch.cgi _______________________________________________________________________________________ CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Manager's information must be completed below PLEASE PRINT CLEARLY Gender: MALE FEMALE Last Name:__________________________________ First Name:________________________ MI:______ Home Address (include PO Box if applicable):__________________________________________________ City:__________________________________ County:__________________ Zip Code:________________ Home Phone Number:_______________________ Business Phone Number:__________________________ Social Security Number:________________________ Drivers License Number & State:________________ Date Of Birth:____________________________ Place Of Birth:___________________________________ Are you married? If yes, complete spouse's information (Even if a spousal affidavit has been submitted) YES NO Spouse's information Spouses Last Name:______________________________ First Name:_____________________ MI:______ Social Security Number:_____________________ Drivers License Number & State:___________________ Date Of Birth:________________________________ Place Of Birth:_______________________________ APPLICANT & SPOUSE MUST LIST RESIDENCE(S) FOR THE PAST TEN (10) YEARS APPLICANT CITY & STATE YEAR YEAR FROM TO SPOUSE CITY & STATE YEAR FROM YEAR TO Form 103 Rev 11/2012 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com MANAGER'S LAST TWO EMPLOYERS YEAR FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non-participation. Has anyone who is a party to this application, or their spouse, EVER been convicted of or plead guilty to any charge. Charge means any charge alleging a felony, misdemeanor, violation of a federal or state law; a violation of a local law, ordinance or resolution. List the nature of the charge, where the charge occurred and the year and month of the conviction or plea. Also list any charges pending at the time of this application. If more than one party, please list charges by each individual's name. YES NO If yes, please explain below or attach a separate page. Name of Applicant Date of Conviction (mm/yyyy) Where Convicted ( city & state) Description of Charge Disposition 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or YES NO any other state? IF YES, list the name of the premise. __________________________________________________________ Do you, as a manager, qualify under Nebraska Liquor Control Act (§53-131.01) and do you intend to supervise, in person, the management of the business? YES NO Have you enclosed the required fingerprint cards and PROPER FEES with this application? (Check or money order made payable to the Nebraska State Patrol for $38.00 per person) YES NO List any alcohol
|
|||||||
