CHANGE OF CORPORATE OFFICERS AND/OR STOCKHOLDERS 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 Website: www.lcc.nebraska.gov/ COMPANY INFORMATION Corporate Name Liquor License Number Corporate Address City State Zip Code Contact Name Contact Telephone Number Corporate Email Address CORPORATE OFFICERS after completion of changes, officers will be as follows: Name: (Last, First, Middle) Date of Birth Social Security Number PRESIDENT/CEO Home Address: (Street) City, State, Zip Code Telephone Number Number of Shares Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number Name: (Last, First, Middle) Date of Birth Social Security Number VICE PRESIDENT Home Address: (Street) City, State, Zip Code Telephone Number Number of Shares Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number Name: (Last, First, Middle) Date of Birth Social Security Number SECRETARY Home Address: (Street) City, State, Zip Code Telephone Number Number of Shares Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number BAR CODE FORM 117 Rev AUG 2016 1 American LegalNet, Inc. www.FormsWorkFlow.com Name: (Last, First, Middle) Date of Birth Social Security Number TREASURER Home Address: (Street) City, State, Zip Code Telephone Number Number of Shares Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number Name: (Last, First, Middle) Date of Birth Social Security Number STOCKHOLDER Home Address: (Street) City, State, Zip Code Telephone Number Number of Shares Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number Name: (Last, First, Middle) Date of Birth Social Security Number DIRECTOR Home Address: (Street) City, State, Zip Code Telephone Number Number of Shares Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number The following needs to be complete by new stockholder(s): 1. READ CAREFULLY, ANSWER COMPLETELY AND ACCURATELY �53-125(5) Has anyone who is a party to this application, or your 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 pending charges at the time of this application. If more than one party, please list charges by each individual's name. INCLUDE TRAFFIC VIOLATIONS. Commission must be notified of any arrests and/or convictions that may occur after the date of signing this form. ___YES ___NO If yes, explain below or attach a separate page If yes, complete the following: Name: (Last, First Middle) Conviction Date (mm/yyyy) Charge Where convicted (city, state) Disposition FORM 117 Rev AUG 2016 2 American LegalNet, Inc. www.FormsWorkFlow.com Fingerprint are required for each new stockholder over 25% new Present/CEO and spouse(s), submit form 147 if fingerprints required. If the spouse(s) have no involvement in the day to day operation of the business they may file an affidavit of non-participation in lieu of fingerprint. Certification by Corporate Contact Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in FBI identification record. The procedures for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34. Under penalty of perjury, I hereby certify that each member is the real party in interest with respect to his/her position and is not acting directly or indirectly as agent, employee or representative of any other person not reported. The undersigned certifies on behalf of the LLC that it is understood that a misrepresentation of fact is cause for rejection of this application or suspension, cancellation or revocation of any license issued. __________________________________________________________________ __________________________ Print Name Title _________________________________________________________________ ___________________________ Signature Date FORM 117 Rev AUG 2016 3 American LegalNet, Inc. www.FormsWorkFlow.com