APPLICATION FOR ADDING SPOUSE 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 _______________________________________________________ Email Address Name: (Last, First, Middle) SPOUSE 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. Has 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, including traffic violations. 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 and Form 147 are required. Fingerprint cards are available at the Liquor Control Commissions office upon request. See Form 147 for instructions. The undersigned applicant(s) hereby consent(s) to an investigation of his/her background and release present and future records of every kind and description including police records, tax records (State and Federal), and bank or lending institution records, and said applicant(s) and spouse(s) waive(s) any right or causes of action that said applicant(s) or spouse(s) may have against the Nebraska Liquor Control Commission, the Nebraska State Patrol, and any other individual disclosing or releasing said information. Any documents or records for the proposed business or for any partner or stockholder that are needed in furtherance of the application investigation of any other investigation shall be supplied immediately upon demand to the Nebraska Liquor Control Commission or the Nebraska State Patrol. The undersigned understand and acknowledge that any license issued, based on the information submitted in this application, is subject to cancellation if the information contained herein is incomplete, inaccurate or fraudulent. _______________________________________________________ Print Spouse's Name ___________________________________________________________________________________________________________________ Spouse's Signature Date Form 148 Rev April 2015 1 American LegalNet, Inc. www.FormsWorkFlow.com