AUTHORIZATION TO CONDUCT INSPECTION ON TRIBAL OR INDIAN LAND Office Use 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 Website: www.lcc.nebraska.gov PROPOSED PREMISE INFORMATION Applicant name: ________________________________________________________________________ Trade name: ____________________________________________________________________________ Premise address: ________________________________________________________________________ City, State, Zip Code: _____________________________________________________________________ County: ________________________________ Nature of business: ______________________________________________________________________ I _________________________________________, hereby authorize any local governing body, law enforcement officer, fire inspector or health inspector to conduct an inspection which is required to license the premise for the sale or consumption of alcohol. ______________________________________________ Signature of Applicant ______________________________ Date BARCODE LABEL FORM 143 REV JULY 2015 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com