Application For Liquor License Nonbeverage {131}

APPLICATION FOR LIQUOR LICENSE NONBEVERAGE CHECKLIST 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 Nonbeverage user means every manufacturer of any of the products set forth and described in subsection (4) of section §53-160, when such product contains alcoholic liquor, and all laboratories, hospitals, and sanatoria using alcoholic liquor for nonbeverage purposes. Applicant Name ________________________________________________________________ Name of Contact Person __________________________________________________________ a. Phone number of Contact Person ______________________________________ E-Mail Address: ________________________________________________________________ Web Site Address: ______________________________________________________________ Provide all the items requested. Failure to provide any item will cause this application to be returned or placed on hold. All documents must be legible. Any false statement or omission may result in the denial, suspension, cancellation or revocation of your license. Prior to submitting your application review the application carefully to ensure that all sections are complete, and that any omissions or errors have not been made. ____________________________________________________________________ Authorized Signature ____________________________________________________________________ Print Name ____________________________________________ Date FORM 131 REV 11/2010 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR LIQUOR LICENSE NONBEVERAGE 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/ CLASS OF LICENSE FOR WHICH APPLICATION IS MADE AND FEES CHECK DESIRED CLASS Type of License: Class N Nonbeverage Application fee $45 plus license fee as follows (check payable to Nebraska Liquor Control Commission) License Fee $5 $25 $50 $100 $250 Class 1 ­ not to exceed 100 gallons Class 2 ­ not to exceed 1,000 gallons Class 3 - not to exceed 5,000 gallons Class 4 ­ not to exceed 10,000 gallons Class 5 - in excess of 10,000 gallons Term of license runs from May 1 ­ April 30 CHECK TYPE OF LICENSE FOR WHICH YOU ARE APPLYING Sole Proprietor (individual) complete section A Partnership License complete section B Corporate License complete section C Limited Liability Company (LLC) complete section D FORM 131 REV 11/2010 PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com PREMISE INFORMATION Trade Name (doing business as)____________________________________________________________________ Street Address #1________________________________________________________________________________ Street Address #2________________________________________________________________________________ City__________________________________County____________________________Zip Code________________ Web address: ___________________________________________________________________________________ Mailing address (where you want to receive mail from the Commission) Name__________________________________________________________________________________________ Street Address #1_________________________________________________________________________________ Street Address #2_________________________________________________________________________________ City___________________________________State____________________________Zip Code________________ SOLE PROPRIETOR (INDIVIDUAL) ­ SECTION A Individual Name_________________________________________________________________________________ Date of Birth_______________________________ Social Security Number_________________________________ Home phone number _______________________________________ Home address _____________________________________________ City _________________________________ State ____________________________________________________ Zip Code _____________________________ E-mail Address ____________________________________________ PARTNERSHIP ­ SECTION B Managing Partner Name___________________________________________________________________________ Date of Birth_______________________________ Social Security Number_________________________________ Home phone number _______________________________________ Home address _____________________________________________ City _________________________________ State ____________________________________________________ Zip Code _____________________________ E-mail Address ____________________________________________ FORM 131 REV 11/2010 PAGE 3 American LegalNet, Inc. www.FormsWorkFlow.com CORPORATION ­ SECTION C Name of Corporation _____________________________________________________________________________ Corporation Address _____________________________________________________________________________ City _________________________________________ State _________________ Zip Code ___________________ Corporation Phone Number ____________________________________ Total number of shares issued out _____________________________ President/CEO Name_____________________________________________________________________________ Date of Birth_______________________________ Social Security Number_________________________________ Home phone number _______________________________________ Home address _____________________________________________ City _________________________________ State ____________________________________________________ Zip Code _____________________________ E-mail Address ____________________________________________ LIMITED LIABILITY COMPANY ­ SECTION D Name of LLC _____________________________________________________________________________ LLC Address _______________________________________________________________________________ City _________________________________________ State _________________ Zip Code ___________________ LLC Phone Number ____________________________________ Managing Member Name__________________________________________________________________________ Date of Birth_______________________________ Social Security Number_________________________________ Home phone number _______________________________________ Home address _____________________________________________ City _________________________________ State ____________________________________________________ Zip Code ______________________