Application For Growler G Endorsement {165}

APPLICATION FOR GROWLER (G) ENDORSEMENT 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 Include application fee of $300 check made payable to the Nebraska Liquor Control Commission or you may pay online at www.ne.gov/go/NLCCpayport MUST be a holder of a Class C, CK, CCS or CKCS liquor license; or making application for same MUST include photo copy of holder's trade name, logo or unique mark used on the containers Standards that shall be met for the sale of Growlers to the final consumer for off premise consumption: o Sale occurs on the licensed premises of the licensee during the hours the licensee is authorized to sell beer; o Licensee uses sanitary containers purchased by the customer from the licensee or exchanged for containers previously purchased by the customer from the licensee; o Containers shall prominently display the endorsement holder's trade name or logo or some other mark that is unique to the endorsement holder; o Shall hold no more than thirty-two (32) ounces; o Licensee seals the container in a manner designed so that it is visibly apparent whether the sealed container has been tampered with or opened or seals the container and places the container in a bag designed so that it is visibly apparent whether the sealed container has been tampered with or opened; o Licensee provides a dated receipt to the customer and attaches a copy of the dated receipt to the sealed container or, if the sealed container is placed in a bag, to the bag Office use only PAYMENT TYPE ___________________ AMOUNT: _________________________ RECEIVED: ______________ RECEIPT#_________________________ BARCODE LABEL FORM 165 REV JULY 2015 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com LIQUOR LICENSE #__________________________________CLASS TYPE________________________ LICENSEE NAME________________________________________________________________________ TRADE NAME___________________________________________________________________________ PREMISE ADDRESS______________________________________________________________________ CITY____________________________________________________________________________________ CONTACT PERSON______________________________________________________________________ PHONE NUMBER OF CONTACT PERSON__________________________________________________ EMAIL ADDRESS OF CONTACT PERSON__________________________________________________ ________________________________________________ Signature of Licensee State of Nebraska County of _____________________________________ The foregoing instrument was acknowledged before me this __________________________________________ by __________________________________________________ Date name of person acknowledged signing document Affix Seal __________________________________________ Notary Public Signature FORM 165 REV JULY 2015 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com