APPLICATION FOR LIQUOR LICENSE INDIVIDUAL INSERT – FORM 1 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 Applicant: Last Name_______________________________________________________________ First Name__________________________________________ MI _________________ Home Address___________________________________City_____________________ Home Telephone Number___________________________________________________ Social Security Number_____________________________Date of Birth ____________ Drivers License Number _______________________________State ________________ Are you married? Yes No If yes, complete the following: Spouses Name (Last, First, Middle) ________________________________________________________________________ Social Security Number_____________________________Date of Birth ____________ Drivers License Number_______________________________State_________________ FORM 35-4182 REV. 2/05 American LegalNet, Inc. www.FormsWorkflow.com