Application To Ship To Wholesalers {107}

NEBRASKA LIQUOR CONTROL COMMISSION APPLICATION FOR LICENSE TO SHIP TO WHOLESALERS 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 Nlcc.spiritwinedesk@nebraska.gov CHECKLIST This application is to obtain a liquor license to ship alcohol to licensed Nebraska wholesalers. MUST SUBMIT APPLICATION FEE OF $1,000.00 MADE PAYABLE TO: NEBRASKA LIQUOR CONTROL COMMISSION or you may pay online at www.ne.gov/go/NLCCpayport · · This is an annual license that runs May 1st through April 30th. This fee is not pro-rated. If applying in the middle of a license year, you may indicate a start date on the application. An email will be sent to the email address provided on the application 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 If at any time during the year you have changes from the original application, notify our office immediately at: nlcc.spiritwinedesk@nebraska.gov · Liquor Shipper Class S Spirits and Wine Instructions and form for filing your monthly report tax return (form 7080) may be found at this link: http://www.lcc.nebraska.gov/spiritwinediv.html. This report is due on or before the 15th of each month; even if no shipments were made during the month. Liquor Shipper Class T Beer Instructions and form for filing your monthly report tax return (form 7099) may be found at this link: http://www.lcc.nebraska.gov/beerdiv.html. This report is due on or before the 15th of each month; even if no shipments were made during the month. American LegalNet, Inc. www.FormsWorkFlow.com FORM 107 REV MAR 2017 PAGE 1 NEBRASKA LIQUOR CONTROL COMMISSION APPLICATION FOR LICENSE TO SHIP TO WHOLESALERS 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 nlcc.spiritwinedesk@nebraska.gov MUST SUBMIT APPLICATION FEE OF $1,000.00 LICENSES RUN MAY 1 ­ APRIL 30 (NO PRORATION) MADE PAYABLE TO: NEBRASKA LIQUOR CONTROL COMMISSION or you may pay online at www.ne.gov/go/NLCCpayport CLASS OF APPLICATION S T SPIRITS AND WINE (SHIPMENT TO WHOLESALER ONLY) BEER (SHIPMENT TO WHOLESALER ONLY) 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) AUTHORIZED AGENT--Include an appointment letter on letterhead from the supplier you represent. 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 American LegalNet, Inc. www.FormsWorkFlow.com FORM 107 REV MAR 2017 PAGE 2 RENEWAL INFORMATION License expires April 30 of each year Renewal notification will be sent by email to the email address provided on the application the first of February. Notify us immediately of any changes (including corporate name, corporate officers, addresses, contact individuals and email contact listed below). Please email changes to nlcc.spirtwinedesk@nebraska.gov 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 Monthly reporting is required ­ on or before the 15th PREMISES INFORMATION ______________________________________________________________________________________________ TRADE NAME (DBA) ______________________________________________________________________________________________ ADDRESS ______________________________________________________________________________________________ CITY STATE ZIP CODE ______________________________________________________________________________________________ PHONE NUMBER FAX NUMBER WEB ADDRESS: _______________________________________________________________________________ E-MAIL ADDRESS : ____________________________________________________________________________ (E-mail address is mandatory. 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 ___________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com FORM 107 REV MAR 2017 PAGE 3 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 _