APPLICATION FOR RESTRICTED FARM WINERY LICENSE NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH, 5TH FLOOR PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 OR (402) 471-2374 Website: www.lcc.ne.gov Office Use 1) ____ Include approval from local governing body (city/county clerk) 2) ____ Include simple hand drawn sketch showing area to be licensed (dimensions in feet) 3) ____ Include lease or deed showing possession of building to be licensed 4) ____ Include business plan §53-123.11 Sell wines produced at the farm winery onsite at wholesale and retail to sell wines produced at the farm winery at off-premises sites holding the appropriate retail license CURRENT CLASS Y LICENSE INFORMATION License # _________________________________________________________________________________ Name of Licensee __________________________________________________________________________ Trade Name (DBA) _________________________________________________________________________ Address __________________________________________________________________________________ City/County/Zip Code _______________________________________________________________________ Phone # __________________________________________________________________________________ Email Address ____________________________________________________________________________ BRANCH OUTLET LOCATION Name of Licensee __________________________________________________________________________ Trade Name (DBA) _________________________________________________________________________ Address __________________________________________________________________________________ City/County/Zip Code _______________________________________________________________________ Phone # __________________________________________________________________________________ _______________________________________________ Signature of licensee FORM 141 REV JULY 2015 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com