REQUEST FOR CHANGE IN PARTNERSHIP 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 ________________________________________________________________________________________________________ Licensee Name Liquor License Number _______________________________________________________________________________________ Premises Address City Zip Code ________________________________________________________________________________________________________ Contact Name Contact Telephone Number List current Partners Submit document showing transfer of ownership Name: (Last, First, Middle) PARTNER Home Address : (Street) Telephone Number Name of Spouse: (Last, First, Middle) Date of Birth Social Security No. Date of Birth City, State, Zip Code Social Security No. Name: (Last, First, Middle) PARTNER Home Address: (Street) Telephone Number Name of Spouse: (Last, First, Middle) Date of Birth City, State, Zip Code Social Security No. Date of Birth Social Security No. Name: (Last, First, Middle) PARTNER Home Address : (Street) Telephone Number Name of Spouse: (Last, First, Middle) Date of Birth City, State, Zip Code Social Security No. Date of Birth Social Security No. Name: (Last, First, Middle) PARTNER Home Address : (Street) Telephone Number Name of Spouse: (Last, First, Middle) Date of Birth City, State, Zip Code Social Security No. Date of Birth Social Security No. FORM 137 REV JULY 2015 1 American LegalNet, Inc. www.FormsWorkFlow.com The following needs to be completed by any new partner: 1. Have you or your spouse ever been convicted of or plead guilty to any charge. Charge means any charge alleging a felony, misdemeanor, violation of a federal or state law; a violation of a local law, ordinance or resolution. List the nature of the change, where the charge occurred and the year and month of the conviction or plea. Also list any charges pending at the time of this application. YES NO If yes, complete the following: Name: (Last, First, Middle) Conviction Date Charge Disposition Location Fingerprints will be required all new members and their spouses. Affidavit of non-participation may be filed by the spouse in lieu of fingerprints, if the spouses they has no involvement in the LLC. Fingerprint cards are available at the Liquor Control Commissions office upon request; fingerprints must to be filed with this affidavit along with processing fee of $38 per person, check made out to the Nebraska State Patrol. Birth Certificates or naturalization papers from the INS, need to be filed on all new members and spouses. Under penalty of perjury, I hereby certify that each member is the real party in interest with respect to his/her position and is not acting directly or indirectly as agent, employee or representative of any other person not reported. The undersigned certifies on behalf of the corporation that it is understood that a misrepresentation of fact is cause for rejection of this application or suspension, cancellation or revocation of any license issued. _______________________________________________________ ________________________________________________ Print Name Title ___________________________________________________________________ ____________________________________ Signature Date FORM 137 REV JULY 2015 2 American LegalNet, Inc. www.FormsWorkFlow.com