Application For Liquor License Partnership Insert-Form 2 (Shipper License) {105}

APPLICATION FOR LIQUOR LICENSE PARTNERSHIP INSERT ­ FORM 2 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.nebraska.gov Office Use Partner(s), including spouses, are required to adhere to the following requirements 1) 2) 3) 4) Must be a citizen of the United States At least one (1) partner must be a Nebraska resident (Chapter 2 ­ 006) Must provide a copy of their certified birth certificate, INS papers or US Passport Fingerprints are required. See Form 147 for further information, this form MUST be included with your application 5) Must sign the signature page of the Application for License form 6) Primary Partner may be required to take a training course 7) Be a registered voter in the State of Nebraska, include a copy of voter registration card with application Name of Primary Partner (Please note if your partnership is a husband/wife combination then opposite spouse will need to complete the additional partner section on the next page) Last Name:________________________________________________________________________________ First Name:_______________________________________________________ MI:______________________ Home Address:_______________________________ City:___________________ Zip Code:______________ Social Security Number:_______________________________ Date of Birth:___________________________ Home Telephone Number:____________________________________________________________________ Driver's 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:___________________________ Driver's License Number: _______________________________________ State:________________________ Form 105 REV JUNE 2015 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Name of additional partner(s) (Please note if the above listed individual is separated, etc. spouse's information is still required to be listed below) Last Name:________________________________________________________________________________ First Name:_______________________________________________________ MI:______________________ Home Address:_______________________________ City:___________________ Zip Code:______________ Social Security Number:_______________________________ Date of Birth:___________________________ Home Telephone Number:____________________________________________________________________ Driver's 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) If yes, provide your spouse's information below YES NO Spouses Last Name: _________________________________________________________________________ Spouses First Name:________________________________________________ MI:_____________________ Social Security Number:_______________________________ Date of Birth:___________________________ Driver's License Number: _______________________________________ State:________________________ If necessary, this page can be copied for additional partner information In compliance with the ADA, this partnership insert form 2 is available in other formats for person with disabilities. A ten day advance period is required in writing to produce the alternate format. Form 105 REV JUNE 2015 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com