CIGAR SHOP EMPLOYEE WAIVER 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 ONLY Statute §53-137(3) "Beginning November 1, 2015, the licensee shall provide to the Commission a copy of a waiver signed prior to employment by each employee on a form prescribed by the Commission. The waiver shall expressly notify the employee that he or she will be exposed to second-hand smoke, and the employee shall acknowledge that he or she understands the risks of exposure to second-hand smoke." LIQUOR LICENSE #______________ LICENSEE NAME_________________________________________________________ TRADE NAME_______________________________ PREMISES ADDRESS___________________________ CITY__________ CONTACT PERSON________________________________________________ PHONE NUMBER________________________ EMAIL ADDRESS OF CONTACT PERSON ____________________________________________________________________ Notice to Employee: By accepting employment with the above identified liquor licensee, you WILL BE exposed to second-hand smoke. (Information on the effects of exposure to second hand smoke can be found on the websites of the American Cancer Society, The U.S. Surgeon General, The American Lung Society & others) I, _____________________________________, acknowledge that I Print name understand the risks of exposure to second-hand smoke _____________________________________________________ _______________________________________ Signature Date BARCODE LABEL FORM 180 REV 11/2015 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com