APPLICATION FOR LIQUOR LICENSE LIMITED LIABILITY COMPANY (LLC) INSERT - FORM 3b 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 All members including spouse(s), are required to adhere to the following requirements: 1) All members spouse(s) must be listed 2) Managing/Contact member and all members holding over 25% interest and their spouse(s) (if applicable) must submit fingerprints. See Form 147 for further information, this form MUST be included with your application. 3) Managing/Contact member and all members holding over 25 % shares of stock and their spouse (if applicable) must sign the signature page of the Application for License form 100 (even if a spousal affidavit has been submitted) Attach copy of Articles of Organization Name of Registered Agent:____________________________________________________________________ Name of Limited Liability Company that will hold license as listed on the Articles of Organization __________________________________________________________________________________________ LLC Address:______________________________________________________________________________ City:_______________________________________ State:_______________ Zip Code:__________________ LLC Phone Number: ______________________________LLC Fax Number____________________________ Name of Managing/Contact Member Name and information of contact member must be listed on following page Last Name:___________________________________ First Name:______________________ MI:__________ Home Address:___________________________________________ City:______________________________ State:________________ Zip Code:________________ Home Phone Number:__________________________ __________________________________________________________________________________________ Signature of Managing/Contact Member ACKNOWLEDGEMENT State of Nebraska County of ____________________________________________ The foregoing instrument was acknowledged before me this _____________________________________________________ by ______________________________________________________ Date name of person acknowledge ____________________________________________________ Affix Seal American LegalNet, Inc. www.FormsWorkFlow.com FORM 102 REV DEC 2015 Page 1 of 4 List names of all members and their spouses (even if a spousal affidavit has been submitted) Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ American LegalNet, Inc. www.FormsWorkFlow.com FORM 102 REV DEC 2015 Page 2 of 4 List names of all members and their spouses (even if a spousal affidavit has been submitted) Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Percentage of member ownership______________________________ American LegalNet, Inc. www.FormsWorkFlow.com FORM 102 REV DEC 2015 Page 3 of 4 Is the applying Limited Liability Company controlled by another corporation/company? YES NO If yes, complete controlling corporation insert form 185 Indicate the company's tax year with the IRS (Example January through December) Starting Date:_____________________________ Ending Date:_______________________________ Is this a Non Profit Corporation? YES NO If yes, provide the