APPLICATION FOR LIQUOR LICENSE CORPORATION/LLC 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: http://www.lcc.ne.gov/ Name of Corporation or Limited Liability Company that will hold license. Attach copy of Articles of Incorporation. (Document must show [barcode] receipt by Secretary of States Office. ______________________________________________________________________________ Corporate Street Address:_________________________________________________________ City:___________________________________State:_____________Zip Code:_____________ Corporate Telephone Number________________________________ Total number of shares issued (if corporation) ________________________________________ Is this a Non Profit Corporation? YES NO If yes, what is your Federal ID #? _____________________________ Name of Registered Agent________________________________________________________ Name of Proposed Manager_______________________________________________________ This person must complete form 35-4013 List name of Chief Executive Officer Last Name:_____________________________________First Name:_____________MI______ Address Street__________________________________City____________________________ State______________Zip Code__________ Home Phone number_________________________ Social Security Number_____________________Date of Birth___________________________ American LegalNet, Inc. www.FormsWorkflow.com List names of all Officers, Directors, Stockholders, Members and their Spouses Last Name_______________________________________First Name_____________________ Social Security Number______________________________Date of Birth__________________ Title__________________________________________Number of Shares_________________ Spouse Name (indicate N/A if single)_______________________________________________ Spouse Social Security Number___________________________Date of Birth______________ Title___________________________________________Number of Shares________________ Last Name_______________________________________First Name_____________________ Social Security Number______________________________Date of Birth__________________ Title__________________________________________Number of Shares_________________ Spouse Name (indicate N/A if single)_______________________________________________ Spouse Social Security Number___________________________Date of Birth______________ Title___________________________________________Number of Shares________________ Last Name_______________________________________First Name_____________________ Social Security Number______________________________Date of Birth__________________ Title__________________________________________Number of Shares_________________ Spouse Name (indicate N/A if single)_______________________________________________ Spouse Social Security Number___________________________Date of Birth______________ Title___________________________________________Number of Shares________________ American LegalNet, Inc. www.FormsWorkflow.com Last Name_______________________________________First Name_____________________ Social Security Number______________________________Date of Birth__________________ Title__________________________________________Number of Shares_________________ Spouse Name (indicate N/A if single)_______________________________________________ Spouse Social Security Number___________________________Date of Birth______________ Title___________________________________________Number of Shares________________ Last Name_______________________________________First Name_____________________ Social Security Number______________________________Date of Birth__________________ Title__________________________________________Number of Shares_________________ Spouse Name (indicate N/A if single)_______________________________________________ Spouse Social Security Number___________________________Date of Birth______________ Title___________________________________________Number of Shares________________ Last Name_______________________________________First Name_____________________ Social Security Number______________________________Date of Birth__________________ Title__________________________________________Number of Shares_________________ Spouse Name (indicate N/A if single)_______________________________________________ Spouse Social Security Number___________________________Date of Birth______________ Title___________________________________________Number of Shares________________ American LegalNet, Inc. www.FormsWorkflow.com Is this Corporation or Limited Liability Company controlled by another Corporation? Yes No If yes, give name of corporation and supply organizational chart ______________________________________________________________________________ Indicate tax year with the IRS Starting Date___________________________Ending Date______________________________ _________________________________________________________ Signature of President/Managing Member _________________________________________________________ Notary Public Signature & Seal Subscribed in my presence and sworn to before me this __________day of____________________, _________ _____________________________________________ Notary Public Signature & Seal In compliance with the ADA, this application for license form is available in other formats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4183 REV. 4/05 American LegalNet, Inc. www.FormsWorkflow.com