APPLICATION FOR SPECIAL DESIGNATED LICENSE NON PROFIT APPLICANTS NEBRASKA LIQUOR CONTROL COMMISSION P.O. Box 95046 Lincoln NE 68509-5046 ALL ISSUED LICENSES ARE MAILED TO LOCAL CLERKS WHERE THE EVENT IS HELD Applications must be received in the Commission Office 10 working days (excluding weekends and holidays) prior to the date of the event Complete and return THE ORIGINAL WITH A DUPLICATE to the Nebraska Liquor Control Commission A license fee of $40 (payable to Nebraska Liquor Control Commission) for each day APPROVAL FROM CITY, VILLAGE OR COUNTY CLERK must be included with this application A Signed Statement from Local Police Chief or County Sheriff Letter from IRS declaring your organization exempt from payment of federal income taxes, or copy of federal tax return, as filed with the IRS, as well as affidavit signed by an officer of the organization declaring that the copy of the tax return is a true and correct copy as filed with the IRS 1. Type of Beverage(s) to be served or consumed: Beer Wine Distilled Spirits 2. Status of applicant (check one): Municipal Political Fine Arts Fraternal Religious Charitable Public Service 3. Name and Address of applicant (as listed on liquor license) (street, city, county, zip code) 4. Address or location of premises to be covered by license, (city, county, zip code) 5. Address of where alcohol is to be stored if other than at location listed in question #4 above 6. Name, address, phone/cell phone number of owner or lessee of premises for which the license is requested 7. DATE(S) OF EVENT (If Sunday, attach Sunday sales ordinance) no more then six (6) consecutive days per application a) If alternate date is requested please list below (must be approved at local level prior to event) ALTERNATE DATE: b) If alternate location is requested please list below (must be approved at local level prior to event) ALTERNATE LOCATION: 8. Time(s) of event (example 8:00 am to 1:00 am, this is considered one day) FROM: TO: 9. Describe type of activity to be carried on during the time period for which the license is requested American LegalNet, Inc. www.FormsWorkflow.com 10. Provide an estimated number of attendees at this event_____________. If the number of attendees is over 150 attach a separate page indicating the steps that will be taken to prevent underage persons access to alcoholic beverages 11. Attach a signed statement from your local police chief or county sheriff, whichever is applicable, that local law enforcement has been informed in advance of this event, and if they are aware of any reason the event should not occur 12. Description of the premises: Inside Building Outdoor Area Dimensions of area to be covered by license:_______________x _______________ Draw in the space provided below area where liquors will be sold and consumed LENGTH WIDTH (feet) If outdoor area, how will premises be separated from areas open to the general public? Fence, Type of fence ______________________________________________________________ Tent Other (explain)___________________________________________________________________ 13. Is the premises to be covered by the license located within the city/village limits?................................. YES NO 14. Is the premises to be covered by the license within 150 feet of any church, school, hospital, or home for the aged or indigent persons or for veterans, their wives or children?................................................................................................ YES NO 15. Is the premises to be covered by the license within 300 feet of any university or college campus........... YES NO 16. Explain how alcoholic liquors will be purchased by the licensee. If purchased from a retail licensee, please give the name and license number _________________________________________________________________________________________________________ (no purchases or sales, i.e. byob) Check here if for consumption only 17. Will the premises to be covered by the license comply with all Nebraska sanitation laws?.................... 18. Are there separate toilets for both men and women?............................................................................ YES YES NO NO 19. Other information or requests for exemptions, must be requested and approved prior to event: American LegalNet, Inc. www.FormsWorkflow.com 20. Will there be any games of chance operating during the event? YES NO If so, describe activity NOTICE: Only games of chance approved by the Department of Revenue, Charitable Gaming Division are permitted. All other forms of gambling are prohibited by State Law: There are no exceptions for Non Profit Organizations or any events raising funds for a charity. This is only an application for a Special Designated License under the Liquor Control Act and is not a gambling permit application. 21. Name and telephone number/cell phone number of immediate supervisor, who will actually be present at the location of the event when it occurs, that can be contacted by law enforcement before and during the event, and who is responsible for ensuring that any applicable laws, ordinances, rules and regulations are adhered to. 22. I declare that I am the authorized representative of the above named license applicant and that the statements made on this application are true to the best of my knowledge and belief. I also consent to an investigation of my background including all records of every kind including police records. I agree to waive any rights or causes of action against the Nebraska Liquor Control Commission, the Nebraska State Patrol or any other individual releasing said information to the Liquor Control Commission or the Nebraska State Patrol. I further declare that the license applied for will not be used by any other person, group, organization or corporation for profit or not for profit and that the event will be supervised by persons directly responsible to the holder of this Special Designated License. sign here _______________________________________________________ ______________________ ________________________ Authorized Representative/Applicant Title Date _______________________________________________________ Print Name sign here________________________________________________________ __________________________ ____________________ Supervisor Title Date ________________________________________________________ Print Name The law requires that no special designated license provided for by this section shall be issued by the Commission without the approval of the local governing body. For the purposes of this section, the local governing body shall be the city or village within which the particular place for which the special designated license is requested is located, or if such place is not within the corporate limits of a city or village, then the local governing body shall be the county within which the place for which the special designated license is requested is located. In Compliance with ADA, this form is available in other formats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format. Rev 7/04 35-4121np American LegalNet, Inc. www.FormsWorkflow.com NEBRASKA LIQUOR CONTROL COMMISSION Application for Special Designated License Under Nebraska Liquor Control Act I HEREBY DECLARE THAT THE CORPORATION MAKING APPLICATION FOR A SPECIAL DESIGNATED LICENSE UNDER THE NEBRASKA LIQUOR CONTROL ACT AS EITHER A MUNICIPAL CORPORATION, A FINE ARTS MUSEUM INCORPORATED AS A NONPROFIT CORPORATION, A RELIGIOUS NONPROFIT CORPORATION WHICH HAS BEEN EXEMPTED FROM THE PAYMENT OF FEDERAL INCOME TAXES, A POLITICAL ORGANIZATION WHICH HAS BEEN EXEMPTED FROM THE PAYMENT OF FEDERAL INCOME TAXES, OR ANY OTHER NONPROFIT CORPORATION, THE PURPOSE OF WHICH IS FRATERNAL, CHARITABLE, OR PUBLIC SERVICE AND WHICH HAS BEEN EXEMPTED FROM THE PAYMENT OF FEDERAL INCOME TAXES AS PER §53-124.11. AS SIGNATORY I CONSENT TO THE RELEASE OR ANY DOCUMENTS SUPPORTING THIS DECLARATION AND ANY DOCUMENTS SUPPORTING THIS DECLARATION WILL BE PROVIDED TO THE NEBRASKA LIQUOR CONTROL COMMISSION, THE NEBRASKA STATE PATROL OR ANY AGENT OF THE LIQUOR CONTROL COMMISSION IMMEDIATELY UPON DEMAND. I ALSO CONSENT TO THE INVESTIGATION OF THIS CORPORATE ENTITY TO DETERMINE IT'S NONPROFIT STATUS. I AGREE TO WAIVE ANY RIGHTS OR CAUSES OF ACTION AGAINST THE NEBRASKA LIQUOR CONTROL COMMISSION, THE NEBRASKA STATE PATROL OR ANY PARTY RELEASING INFORMATION TO THE AFOREMENTIONED PARTIES. NAME OF CORPORATION: __________________________________ FEDERAL TAX ID NUMBER: _______________________________ ________________________________________________________ SIGNATURE OF TITLE OF CORPORATE OFFICERS THE ABOVE INDIVIDUAL STATES THAT THE STATEMENT ABOVE IS TRUE AND CORRECT: IF ANY FALSE STATEMENT IS MADE ON THIS APPLICATION, THE APPLICANT SHALL BE DEEMED GUILTY OF PERJURY AND SUBJECT TO PENALTIES PROVIDED BY LAW. (SEC. §53131.01). NEBRASKA LIQUOR CONTROL ACT SUBSCRIBED IN MY PRESENCE AND SWORN TO BEFORE ME THIS__________ DAY OF____________________,________. __________________________________________________ NOTARY PUBLIC SIGNATURE & SEAL American LegalNet, Inc. www.FormsWorkflow.com