Application fo License for Airlines, Railroads, Nonbeverage Under the Nebraska Liquor Control Act

NEBRASKA LIQUOR CONTROL COMMISSION

Application fo License for
Airlines, Railroads, Nonbeverage
Under the Nebraska Liquor Control Act

INSTRUCTIONS: Mail application and appropriate fees as listed below to: P.O. Box 95046, Lincoln, NE 68509-5046 **Please Type or Print

CLASS OF LICENSE FOR WHICH APPLICATION IS MADE AND LIST OF FEES FOR EACH
Class of License (Check applicable class)		Registration Fee	License Fee
R Railroad License		$45.00	$100.00
P Airline License		$45.00	$100.00
N Nonbeverage User License
	Class 1	$45.00	$5.00
	Class 2	$45.00	$25.00
	Class 3	$45.00	$50.00
	Class 4	$45.00	$100.00
	Class 5	$45.00	$250.00
Duplicate Licenses		License Fee	# Requested
Duplicate Railroad License		$1.00
Duplicate Airline License		$1.00

TYPE OF APPLICATION
Type of Application Being Applied for (place appropriate number in box)
		1 = Individual License (Requires Form 1) 2 = Partnership License (Requires Form 2) 3 = Corporate License (Requires Form 3)

PREMISE INFORMATION - Must be completed by all applicants
Trade Name	Telephone Number -
Street Address of Proposed Licensed Premise (1)	Mailing Address of Proposed License Premice (2)
City	State
Zip Code -

Questions for all Applicants			Comments/Explanation Only visible text will be printed
1. Will any person or persons other than named on this application (partners, corporate officers, directors) have any interest directly or indirectly in this business? If yes, explain.	Yes	No
2. Does anyone named on this application, including corporate officers or stockholders, hold a current Nebraska Alcoholic Beverage License? If yes, list licenses and date acquired.	Yes	No
3. READ CAREFULLY. Answer completely and accurately. Has anyone who is a party to this application, or their spouse, ever been convicted of or plead guilty to any criminal charge? Criminal charge means any charge alleging a felony or misdemeanor or violation of a federal or state law; or a violation of a local law, ordinance or resolution. List the nature of the charge, where the charge occurred and the year and month of the conviction or plea. The includes DUIs or DWIs. Also list any charges pending at the time of this application. If more than one party, please list charges by each individual's name.	Yes	No
4. Do you intend to manage yourself?	Yes	No
5. Are all persons named on this application, including spuses of persons named on this application, citizens of the United States? If NO, list names.	Yes	No

PERSONAL OATH AND CONSENT TO INVESTIGATION

Must be signed in the presence of a notary public. Must be signed by applicant and spouse; if a partnership, all partners and spouses must sign and corporation, all stockholders/members (holding more than 25% of the stock or interest), officers, directors and spouses must sign. Full names only, initials not acceptable.

The undersigned applicant(s) hereby consent(s) to a background investigation and release of present & future records of every kind and description including police records, tax records (State and Federal), bank or lending institution records, and said applicant(s) and spouse(s) waive(s) any right of causes of action that said applicant(s) or spouse(s) may have against the Nebraska Liquor Control Commission, the Nebraska State Patrol, and any other individual disclosing or releasing said information. Any documents or records for the proposed business or for any partner or stockholder that are needed in furtherance of the application investigation or any other investigation shall be supplied immediately upon demand to the Nebraska Liquor Control Commission or the Nebraska State Patrol. The undersigned understand and acknowledge that any license issued, based on the information submitted in this application, is subject to cancellation if the information contained herein is incomplete and/or inaccurate.

Signature: ______________________________________

subscribed in my presence and sworn to before me this _____________day of ________________, ________.

Signature_______________________________________________

Notary Public & seal

Form 35-4150