Nebraska Liquor Control Commission Application for License to Ship Alcoholic Liquors into the State of Nebraska Under the Nebraska Liquor Control Act **Please type or Print All fees payable to: Nebraska Liquor Control Commission Mail to: PO Box 95046, Lincoln NE 68509-5046 CLASS OF LICENSE FOR WHICH APPLICATION IS MADE AND LIST OF FEES FOR EACH Class of license - check applicable class(s) License fees S Spirits and Wine (shipment to wholesaler only) $200.00 T Beer (shipment to wholesaler only) $200.00 S1 Direct Alcohol Sales (direct shipment to consumer only) TYPE OF APPLICATION $500.00 TYPE OF OPERATION (CHECK ONE) Type of Application Being Applied for Manufacturer Agent include a signed statement from the Individual License (requires form 1) manufacturer(s) stating that you have been appointed to represent their company. Partnership License (requires form 2) Corporate License (requires form 3) PREMISE INFORMATION - MUST BE COMPLETED BY ALL APPLICANTS TRADE NAME TELEPHONE NUMBER ( FAX NUMBER ( ) E-MAIL ADDRESS ) STREET ADDRESS OF PROPOSED LICENSED SHIPPER CITY COUNTY STATE ZIP MAILING ADDRESS FOR RECEIPT OF LIQUOR CONTROL COMMISSION MAILINGS CITY COUNTY STATE ZIP Form 35-4016 Rev 8/01 Page 1 American LegalNet, Inc. www.FormsWorkflow.com 1. Do you have more than one shipping point? YES NO If yes, list all points 2. Will the premises and shipping points listed above be open and records available for inspection by our NO examiners at all reasonable hours? YES If yes, when and where?__________________________________________________________________ 3. Has any previous license or permit relating to alcoholic liquors, municipal, state or federal, issued to you NO ever been revoked or suspended? YES If yes, when and where?__________________________________________________________________ 4. If an individual or partnership, does any partner or owner hold a retail, wholesale, or distributor license NO under the Nebraska Liquor Control Act? YES 5. If a corporation, does the corporation, any employee, officer or agent of the corporation, or any person holding more than 25% of the corporate stock, hold a retail, wholesale, or distributor license under the NO Nebraska Liquor Control Act? YES If yes, give names: ______________________________________________________________________ 6. Is this license to replace an existing license? YES NO If yes, include name and license number of existing licensee:____________________________________ 7. 8. In consideration of the issuance of this license, we agree to the following and understand that failure of full compliance may result in suspension or revocation of license: 1. To comply with and be bound by the provisions of Section §53-162, §53-164.01 and §53-165; R.R.S. Neb., as amended, pertaining to the making and filing of returns, and the keeping of records. 2. To permit and be subject to all of the powers granted by the provisions of Section §53-164.01 and §53-165; R.R.S. Neb., as amended, to the Nebraska Liquor Control Commission or its duly authorized employees or agents for inspection and examination of the premises and the records; and to pay actual expenses excluding salary, reasonably attributable to such inspections and examinations made by duly authorized employees of the Nebraska Liquor Control Commission, if within the United States; and 3. To comply with and be bound with §53-192 & §53-194.03; and 4. If any licensee violates any of the provisions of this application or of the provisions of the NE Liquor Control Act, or the rules and regulations of the NE Liquor Control Commission that apply to manufacturers, the NE Liquor Control Commission may revoke or suspend such license as provided by law. What is your Federal Basic Permit Number? ___________________________ Please ATTACH a copy of your Permit from the Bureau of Alcohol, Tobacco & Firearms. If you are an Agent for one or more Manufacturer(s), you will need to ATTACH a copy of the Federal Basic Permit # for each Manufacturer(s) your company represents. Form 35-4016 Rev 8/01 Page 2 American LegalNet, Inc. www.FormsWorkflow.com PERSONAL OATH AND CONSENT TO INVESTIGATE This must be signed in the presence of a notary public. It must be signed by the APPLICANT, if a partnership, ALL PARTNERS must sign, if corporation, PRESIDENT AND OTHER PRINCIPAL OFFICERS must sign. Applicant’s Name(s) The above individual(s) being first duly sworn upon oath, depose(s) and state(s) that the undersigned is/are the applicant(s) who make(s) the above and foregoing application, that this application has been read and that the contents thereof and all statements contained therein are true. The Undersigned applicant(s) hereby consent(s) to a background investigation and release of present & future records of every kind and description including police records, tax records (State and Federal), bank or lending institution records, and the 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 or 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 and/or inaccurate. SIGN HERE_____________________________________ SIGN HERE__________________________________ SIGN HERE____________________________________ SIGN HERE__________________________________ Subscribed in my presence and sworn to before me this ______________day of_________________________, __________ (SEAL) SIGN HERE_______________________________________________________ Notary Public Form 35-4016 Rev 8/01 Page 3 American LegalNet, Inc. www.FormsWorkflow.com