APPLICATION FOR LIQUOR LICENSE CORPORATION MANAGER - FORM 3b *MUST BE A NEBRASKA RESIDENT* 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 Website: http://www.lcc.ne.gov/ LIQUOR LICENSE INFORMATION NAME OF LICENSED CORPORATION_____________________________________________________________________________ CLASS & LICENSE NUMBER______________________________________ TRADE NAME__________________________________________________________________________________________________ STREET ADDRESS____________________________________________CITY_____________________________________________ _______________________________________________________________________________________________________________ SIGNATURE OF CORPORATION PRESIDENT/CEO APPLICANT INFORMATION (MUST BE 21 OR OVER AND NEBRASKA RESIDENT) NAME_________________________________________________________________________________________________________ ADDRESS______________________________________________________________________________________________________ CITY_________________________________________________STATE________________ZIP CODE__________________________ HOME PHONE NUMBER____________________________________BUSINESS PHONE NUMBER____________________________ SEX MALE FEMALE SOCIAL SECURITY NUMBER__________________________ DATE OF BIRTH________________________________PLACE OF BIRTH__________________________ DRIVERS LICENSE NUMBER & STATE______________________________________________________ SPOUSES INFORMATION (IF NOT MARRIED INDICATE) SPOUSE NAME___________________________________________________________________ SOCIAL SECURITY NUMBER_______________________________________DATE OF BIRTH_____________________________ DRIVERS LICENSE NUMBER & STATE______________________________________________ American LegalNet, Inc. www.FormsWorkflow.com FORM 35-4013 REV. 4/05 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Has anyone who is a party to this application, or their 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 charge, 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. If more than one party, please list charges by each individual’s name. YES NO If yes, please explain below or attach a separate page. 2. Have you or your spouse ever made application for any liquor license or manager for any liquor license? IF YES, for what premise give license number and date. YES NO 3. Have you or your spouse ever made a compromise settlement for violation of such laws? YES NO 4. Do you, as a manager, have all the qualifications required by any person entitled to hold a Nebraska Liquor License? Nebraska Liquor Control Act (§53-131.01) YES NO 5. Have you filed fingerprint cards and PROPER FEES (if check, make out to the NE State Patrol), with this application? YES NO RESIDENCES FOR THE PAST 10 YEARS, APPLICANT AND SPOUSE MUST COMPLETE APPLICANT: CITY & STATE YEAR FROM TO SPOUSE: CITY & STATE YEAR FROM TO EMPLOYERS - LIST LAST TWO EMPLOYERS MONTH/YEAR FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER American LegalNet, Inc. www.FormsWorkflow.com FORM 35-4013 REV. 4/05 PERSONAL OATH AND CONSENT OF INVESTIGATION MUST BE SIGNED BY APPLICANT & SPOUSE The above individual(s), being first duly sworn upon oath, deposes and states that the undersigned is the applicant and/or spouse of applicant who makes the above and foregoing application, that said application has been read and that the contents thereof and all statements contained therein are true. If any false statement is made in any part of this application, the applicant(s) shall be deemed guilty of perjury and subject to penalties provided by law. (Sec. §53-131.01) Nebraska Liquor Control Act. The undersigned applicant hereby consents to an investigation of his/her background including all records of every kind and description including police records, tax records (State and Federal), and bank or lending institution records, and said applicant and spouse waive any rights or causes of action that said applicant or spouse may have against the Nebraska Liquor Control Commission and any other individual disclosing or releasing said information to the Nebraska Liquor Control Commission. If spouse has NO interest directly or indirectly, an affidavit of non participation may be attached. 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. ___________________________________________________________________ Signature of Applicant ____________________________________________________________________ Signature of Spouse Subscribed in my presence and sworn to before me this ___________________ day of _____________________________. Subscribed in my presence and sworn to before me this ____________ day of ___________________________. ___________________________________________________________________ Notary Signature & Seal ___________________________________________________________________ Notary Signature & Seal American LegalNet, Inc. www.FormsWorkflow.com FORM 35-4013 REV. 4/05