APPLICATION FOR ADDITION, DELETION, CHANGE OF LOCATION, RECONSTRUCTION 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.ne.gov FEE $45.00 LICENSEE’S NAME______________________________________________________ TRADE NAME__________________________________________________________ PREMISE ADDRESS_____________________________________________________ CITY/COUNTY__________________________________________________________ LICENSE NUMBER___________________ PHONE NUMBER___________________ PLEASE CHECK ONE OF THE FOLLOWING ___ADDITION ___RECONSTRUCTION __DELETION ___CHANGE OF LOCATION (this application will not be accepted if the license is moving into another jurisdiction) Address From:_________________________________________________________________ Address To:____________________________________________________________________ 1) Include a sketch of the proposed area to be licensed (8 ½ x 11 paper – no blueprints) indicate the dimensions of the area to be licensed and the direction “north” on the sketch 2) Submit a copy of your lease or deed demonstrating ownership 3) If you do not know what jurisdiction you are located in, call the city or county clerk 4) In order to clarify your changes, an attached explanation is always welcome AFFIDAVIT The above reference request, as filed, will comply with the rules and regulations of the Nebraska Liquor Control Act. ____________________________________________________ Signature of licensee Subscribed in my presence and first duly sworn to before me on this ___________day of _______________________________, __________. __________________________________________________ Notary Public signature and seal FORM 35-4179 American LegalNet, Inc. www.FormsWorkflow.com