APPLICATION FOR CHANGE OF LOCATION TO LIQUOR LICENSE 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 Application: Must include processing fee of $45.00 checks made payable to Nebraska Liquor Control Commission (NLCC) or you may pay online at www.ne.gov/go/NLCCpayport Must include a copy of the lease, deed or purchase agreement showing ownership of new location. This document must read in the name liquor license is issued to, i.e. if license is issued to a corporation must read corporate name Must include simple hand drawn sketch of new location, must include outside dimensions in feet (not square feet), showing direction north NO BLUE PRINTS May include approval from the local governing body; new location shall not be approved unless endorsed by the local governing body Check with your local governing body for any additional requirements that may be necessary in making this request for addition Change of location application will not be accepted if moving to a different jurisdiction (i.e. city or county); a new application will need to be filed. LIQUOR LICENSE #___________________________________CLASS TYPE_______________________ LICENSEE NAME_________________________________________________________________________ TRADE NAME____________________________________________________________________________ CURRENTLY LICENSED ADDRESS________________________________________________________ CITY_________________________ZIP CODE________________COUNTY_________________________ CONTACT PERSON_______________________________________________________________________ PHONE NUMBER OF CONTACT PERSON___________________________________________________ EMAIL ADDRESS OF CONTACT PERSON__________________________________________________ BARCODE LABEL FORM 111 REV APR 2015 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com NEW PREMISE Street Address #1__________________________________________________________________________ Street Address #2__________________________________________________________________________ Zip Code_________________________ New Premise Phone Number_______________________________ Business e-mail address_____________________________________________________________________ MAILING ADDRESS FOR NEW LOCATION Street Address #1__________________________________________________________________________ Street Address #2__________________________________________________________________________ City___________________________________________State__________Zip Code_____________________ 1. Describe the new building to be licensed Include sketch of building to be licensed with length & width in feet If outdoor area to be licensed include on sketch with length & width Indicate the direction north Indicate single story building or give number of floors, how many are licensed Indicate if there is a basement to be included in the licensed description Include proof of ownership (must be in the name liquor license is issued under) deed purchase agreement lease; date lease expires ________________________________ 2. 3. Is the new premise location within 150 feet of a church, school, hospital, home for the aged or indigent persons or for veterans, their wives, and children; or within 300 feet of a college or university campus? YES NO If yes, provide name and address of such institution and where it is located in relation to the premises (Neb. Rev. Stat. 53-177)(1). Must include supplemental Form 134 found at this link: http://www.lcc.ne.gov/formsdiv.html _________________________________________________________________________________________ If proposed location is within 300 feet of a campus, the Commission may waive this restriction upon written approval from the governing body of the college or university. (Rev. Stat. 53-177)(1). Must include supplemental Form 135 found at this link: http://www.lcc.ne.gov/formsdiv.html 4. When do you expect on moving into the new location? _____________________________________ FORM 111 REV APR 2015 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com I acknowledge under oath that the premises into which such move is made comply in all respects with the requirements of the act. Neb Rev Stat §53-129 ________________________________________________ Signature of Licensee or Officer State of Nebraska County of _____________________________________ The foregoing instrument was acknowledged before me this __________________________________________ by __________________________________________________ Date name of person acknowledged (individual(s) signing document) Affix Seal __________________________________________ Notary Public signature FORM 111 REV APR 2015 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com