APPLICATION FOR SACRAMENTAL WINE PERMIT 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 CHURCH OR RELIGIOUS ORGANIZATION DESIRING SACRAMENTAL WINE PERMIT: Premises Information: Name: ___________________________________________________________________________________ Address: ________________________________________City: ____________________________________ County: ________________________________________ Zip Code: ________________________________ Phone number: __________________________________ Federal ID #______________________________ Contact Information Name: ___________________________________________________________________________________ Address: ________________________________________City: ____________________________________ County: ________________________________________ Zip Code: ________________________________ Phone number: __________________________________ Email Address: ___________________________________________________________________________ _____Currently have permit # ___________ _____ Lost permit need duplicate _____ Do not need permit please cancel Contact Signature: ________________________________________________Date: ___________________ FORM 170 REV MAR 2016 American LegalNet, Inc. www.FormsWorkFlow.com