Privacy Act Statement Submission Of Fingerprints Payment Of Fees To NSP CID {147}

FORM 147 REV OCT 2015 PAGE 1 SUBMISSSION OF FINGERPRINTS / PAYMENT OF FEES TO NSP-CID 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 Applicant N ame : (Corporation, LLC, Partnership or Individual) Trade N ame : (Doing Business As) ( ) - Phone Number Contact E-mail Address DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: See New Application Requirement Guide for listing of Fingerprint Requirements, found on our website Fingerprints taken at NSP locations will be forwarded to NSP CID; Applicant(s) will not have cards to include with license application. Fingerprints taken at local law enforcement offices will be released to the applicants; Fingerprint cards should be submitted with the application. Fee payment of $28.75 per person must be made directly to the NSP; You may submit the payment through the NSP PayPort online system at www.ne.gov/go/nsp or checks made payable to NSP should be mailed directly to the following address: The Nebraska State Patrol CID Division 3800 NW 12th Street Lincoln, NE 68521 DO NOT send fee payments to the NLCC fees MUST be paid directly to NSP; Include a list of names covered by your payment to insure proper application of payment. This completed form MUST be included with your Liquor License Application and/or Manager Application or Changes to: Corporate Officers or Stockholders, LLC Members, Partners or Addition of Spouse where new fingerprint cards are required (see New Application Requirement Guide). Fingerprints are not required for spouses that have no involvement with business - Spousal Affidavit of Non Participation (Form 116) is required in lieu of fingerprints. Please complete information on the following pages for EACH person fingerprinted. DATE R ECEIVED Office Use Only License # : Class: American LegalNet, Inc. www.FormsWorkFlow.com FORM 147 REV MAR 2015 PAGE 2 1. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSP? NSP PAYPORT Or CHECK SENT TO NSP Ck # 2. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSP? NSP PAYPORT Or CHECK SENT TO NSP Ck # 3. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSP? NSP PAYPORT Or CHECK SENT TO NSP Ck # 4. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSP? NSP PAYPORT Or CHECK SENT TO NSP Ck # 5. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSP? NSP PAYPORT Or CHECK SENT TO NSP Ck # 6. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSP? NSP PAYPORT Or CHECK SENT TO NSP Ck # I hereby certify that fees of $28.75 per person have been submitted directly to the Nebraska State Patrol CID office . The undersigned certifies on behalf of the Corporation, LLC, Partnership or Licensee that it is understood that a misrepresentation of fact is cause for rejection of this application or suspension, cancellation or revocation of any license issued. Name (Print) : Title : Signature : Date : American LegalNet, Inc. www.FormsWorkFlow.com