Application For Liquor License Individual Insert-Form 1 (Shipper License) {104}

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.nebraska.gov Office Use Individual applicants, including spouse, are required to adhere to the following requirements 1) 2) 3) 4) 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, 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) Applicant 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 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:____________________________________________________________________ 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:________________________ American LegalNet, Inc. www.FormsWorkFlow.com Form 104 REV JUNE 2015 Page 1