Nebraska > Statewide > Liquor Control Commission
Application For Liquor License Individual Insert-Form 1 (Shipper License) 35-4182shpr - Nebraska
| Application For Liquor License Individual Insert-Form 1 (Shipper License) Form. This is a Nebraska form and can be used in Liquor Control Commission Statewide . |
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APPLICATION FOR LIQUOR LICENSE INDIVIDUAL INSERT FORM 1 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 Individual applicants, including spouse, are required to adhere to the following requirements 1) 2) 3) 4) 5) 6) Must be a citizen of the United States Must be a Nebraska resident (Chapter 2 006) Must provide a copy of their certified birth certificate or INS papers Must submit their fingerprints (2 cards per person) Must sign the signature page of the Application for License form Applicant may be required to take a training course Name of individual applicant who will hold license Last Name:________________________________________________________________________________ First Name:_______________________________________________________ MI:______________________ Home Address:_______________________________ City:___________________ Zip Code:______________ Social Security Number:_______________________________ Date of Birth:___________________________ Home Telephone Number:____________________________________________________________________ Drivers License Number: __________________________________________ State:______________________ Are you married? (Please note if the above listed individual is separated, etc. spouse's information is still required to be listed below) YES NO If yes, provide your spouse's information below Spouses Last Name: _________________________________________________________________________ Spouses First Name:________________________________________________ MI:_____________________ Social Security Number:_______________________________ Date of Birth:___________________________ Drivers License Number: ________________________________________ State:________________________ In compliance with the ADA, this individual insert form 1 is available in other formats for person with disabilities. A ten day advance period is required in writing to produce the alternate format. FORM 35-4182 REVISED 05/2007 American LegalNet, Inc. www.FormsWorkFlow.com
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