Application For License To Ship Direct To Consumers (S1) {142}

NEBRASKA LIQUOR CONTROL COMMISSION APPLICATION FOR LICENSE TO SHIP DIRECT TO CONSUMERS (S1) 301 CENTENNIAL MALL SOUTH. 5TH FLOOR PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 or (402) 41-2374 Website: www.lcc.nebraska.gov CHECKLIST 1. This application is to obtain a liquor license to ship alcohol direct to consumers in the State of Nebraska. 2. This is an annual license that runs May 1st through April 30th. An email will be sent, the first week of February as a reminder of the renewal period; however, it is your responsibility to renew prior to expiration. Link to renew: https://www.nebraska.gov/nlcc/renewals/index.cgi 3. If at any time during the year you have changes from the original application, notify our office immediately at: nlcc.spiritwinedesk@nebraska.gov 4. Instructions and form for filing your annual tax return (form 7140) may be found at this link: http://www.lcc.ne.gov/spritwinediv.html. This report and excise taxes owed are due on or before the 25th of January. Sales tax is owed to the Nebraska Department of Revenue for further information go to: www.revenue.ne.gov 5. Complete a Nebraska Tax Application, form 20 6. Manufacturers, Craft Breweries, Craft Distilleries & Farm Wineries must file a list of brand name(s) on company letterhead of alcoholic liquor requesting authority to ship into Nebraska direct to Nebraska Wholesalers FORM 142 REV MAR 2017 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com NEBRASKA LIQUOR CONTROL COMMISSION APPLICATION FOR LICENSE TO SHIP DIRECT TO CONSUMERS (S1) 301 CENTENNIAL MALL SOUTH. 5TH FLOOR PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 or (402) 41-2374 Website: www.lcc.nebraska.gov MUST SUBMIT APPLICATION FEE OF $500.00 MADE PAYABLE TO: NEBRASKA LIQUOR CONTROL COMMISSION TYPE OF APPLICATION (check one) INDIVIDUAL PARTNERSHIP LIMITED LIABILITY COMPANY (LLC) CORPORATION TYPE OF OPERATION AS DESCRIBED IN §53-123.15 (check one) MANUFACTURER/BREWER (defined under Neb Rev Stat §53-103.20) IMPORTER/WHOLESALER (defined under Neb Rev Stat §53-103.41) IF RETAILER CHECK BOX LICENSED RETAILER (defined under Neb Rev Stat §53-103.31) Within Nebraska Outside Nebraska FEDERAL BASIC PERMIT Federal Basic Permit number ________________________ Copy of permit is enclosed STATE INFORMATION State License number ______________________________ Name of State License issued ________________________ Copy of license is enclosed FORM 142 REV MAR 2017 PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com RENEWAL INFORMATION License expires April 30 of each year Renewal notification will be sent by email the first of February. Notify us immediately of any changes (including corporate name, corporate officers, addresses, contact individuals and email contact listed below) Renewal period starts February 1st; renew your license on-line at https://www.nebraska.gov/nlcc/renewals/index.cgi th NO PAPER RENEWAL FORMS WILL BE ACCEPTED No monthly reporting is required ­ annual report is due January 25th PREMISE INFORMATION ______________________________________________________________________________________________ TRADE NAME (DBA) ______________________________________________________________________________________________ ADDRESS ______________________________________________________________________________________________ CITY STATE ZIP CODE ______________________________________________________________________________________________ PHONE NUMBER FAX NUMBER WEB ADDRESS: _______________________________________________________________________________ E-MAIL ADDRESS: ____________________________________________________________________________ (This address will be used to request any information needed on application or questions on future reports and notification of renewal) MAILING ADDRESS IF DIFFERENT FROM ABOVE ______________________________________________________________________________________________ ADDRESS ______________________________________________________________________________________________ CITY STATE ZIP CODE COMPLIANCE COMPANY INFORMATION Check, if this is a compliance company Compliance company name ____________________________________________________________________ Name of compliance company contact ____________________________________________________________ Email of compliance company contact ___________________________________________________________ FORM 142 REV MAR 2017 PAGE 3 American LegalNet, Inc. www.FormsWorkFlow.com SOLE PROPRIETOR Individual Name_________________________________________________________________________________ Date of Birth_______________________________ Phone number _______________________________________ Fax number _________________________________ Home address _____________________________________________ City _________________________________ State ____________________________________________________ Zip Code _____________________________ PARTNERSHIP Managing Partner Name___________________________________________________________________________ Date of Birth_______________________________ Phone number __________________________________Fax Number ______________________________________ Home address _____________________________________________ City _________________________________ State ____________________________________________________ Zip Code _____________________________ Enclose a list of all partners, show names only. LIMITED LIABILITY CORPORATION (LLC) Name of Corporation _____________________________________________________________________________ Corporate Address _______________________________________________________________________________ City _________________________________________ State _________________ Zip Code ___________________ Phone Number ____________________________________ Fax Number ___________________________________ Managing Member Name__________________________________________________________________________ Date of Birth_______________________________ Home phone number _______________________________________ Home address _____________________________________________ City _________________________________ State ____________________________________________________ Zip Code _____________________________ Enclose list of all members of the LLC, must show names only. FORM 142 REV MAR 2017 PAGE 4 American LegalNet, Inc. www.FormsWorkFlow.com CORPORATION Name of Corporation _____________________________________________