APPLICATION FOR LIQUOR LICENSE CORPORATION INSERT - FORM 3a 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 Officers, directors and stockholders holding over 25% shares of stock, including spouses, are required to adhere to the following requirements: 1) All officers, directors and stockholders must be listed 2) President/CEO and stockholders holding over 25% and their spouse(s) (if applicable) must submit fingerprints. See Form 147 for further information, this form MUST be included with your application. 3) Officers, directors and stockholders holding over 25 % shares of stock and their spouse (if applicable) must sign the signature page of the Application for License Form 100 (even if a spousal affidavit has been submitted) Attach copy of Articles of Incorporation Name of Registered Agent:____________________________________________________________________________ Name of Corporation that will hold license as listed on the Articles __________________________________________________________________________________________________ Corporation Address:________________________________________________________________________________ City:_______________________________________ State:___________________ Zip Code:______________________ Corporation Phone Number: ____________________________Fax Number____________________________________ Total Number of Corporation Shares Issued:______________________________________________________________ Name and notarized signature of President/CEO (Information of president must be listed on following page) Last Name:____________________________________ First Name:___________________________ MI:____________ Home Address:_____________________________________________ City:____________________________________ State:____________________ Zip Code:__________________ Home Phone Number:____________________________ ___________________________________________________________________________________________ Signature of President/CEO ACKNOWLEDGEMENT State of Nebraska County of ____________________________________________ The foregoing instrument was acknowledged before me this _____________________________________________________ by ______________________________________________________ Date name of person acknowledge ____________________________________________________ Affix Seal American LegalNet, Inc. www.FormsWorkFlow.com FORM 101 REV DEC 2015 Page 1 of 4 List names of all officers, directors and stockholders including spouses (even if a spousal affidavit has been submitted) Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ American LegalNet, Inc. www.FormsWorkFlow.com FORM 101 REV DEC 2015 Page 2 of 4 List names of all officers, directors and stockholders including spouses (Even if a spousal affidavit has been submitted) Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Last Name:____________________________________ First Name:__________________ MI:_______ Social Security Number:_____________________________ Date of Birth:_______________________ Title:________________________________________ Number of Shares ________________________ Spouse Full Name (indicate N/A if single):_________________________________________________ Spouse Social Security Number:___________________________ Date of Birth:___________________ Amer