Form 103 Rev Jan 2018 Page 1 of 6 MANAGER APPLICATION INSERT - FORM 3c 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 FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MANAGER MUST: Complete all sections of the application. Be sure it is signed by a member or corporate officer, corporate officer or member must be an individual on file with the Liquor Control Commission Fingerprints are required. See form 147 for further information, read form carefully to avoid delays in processing, this form MUST be included with your application. Provide a copy of one of the following: US birth certificate, naturalization papers or current US passport (even if you have provided this before) Be a registered voter in the State of Nebraska, include a copy of voter card or print document from Secretary of State website with application Spouse who will not participate in the business, spouse must: Complete the Spousal Affidavit of Non Participation Insert (must be notarized). The non-participating spouse completes the top half; the manager completes the bottom half. Be sure to complete both halves of this form. Need not answer question #1 of the application Spouse who will participate in the business, the spouse must: Sign the application Fingerprints are required. See form 147 for further information, read form carefully to avoid delays in processing, this form MUST be included with your application. Provide a copy of one of the following: birth certificate, naturalization papers or current US passport (even if you have provided this before) Be a registered voter in the state of Nebraska, include a copy of voter card with application Spousal Affidavit of Non Participation Insert not required Office Use BARCODE American LegalNet, Inc. www.FormsWorkFlow.com Form 103 Rev Jan 2018 Page 2 of 6 MANAGER APPLICATION INSERT - FORM 3c 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 MUST BE: Citizen of the United States. Include copy of US birth certificate, naturalization paper or current US passport Nebraska resident. Include copy of voter registration card or print out document from Secretary of State website Fingerprinted. See form 147 for further information, read form carefully to avoid delays in processing, this form MUST be included with your application 21 years of age or older Corporation/LLC information Name of Corporation/LLC: Premise information Liquor License Number: Class Type (if new application leave blank) Premise Trade Name/DBA: Premise Street Address: City:County:Zip Code: Premise Phone Number: Premise Email address: The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b or listed with the Commission. To see authorized officers or members search your license information here. SIGNATURE REQUIRED BY CORPORATE OFFICER / MANAGING MEMBER (Faxed signatures are acceptable) Office Use American LegalNet, Inc. www.FormsWorkFlow.com Form 103 Rev Jan 2018 Page 3 of 6 Manager222s information must be completed below PLEASE PRINT CLEARLY Last Name: First Name: MI: Home Address: City: County: Zip Code: Home Phone Number: Driver222s License Number & State: Social Security Number: Date Of Birth: Place Of Birth: Email address: Are you married? If yes, complete spouse222s information (Even if a spousal affidavit has been submitted) YES NO Spouse222s information Spouses Last Name: First Name: MI: Social Security Number: Driver222s License Number & State: Date Of Birth: Place Of Birth: APPLICANT & SPOUSE MUST LIST RESIDENCE(S) FOR THE PAST TEN (10) YEARS APPLICANT SPOUSE CITY & STATE YEAR FROM YEAR TO CITY & STATE YEAR FROM YEAR TO American LegalNet, Inc. www.FormsWorkFlow.com Form 103 Rev Jan 2018 Page 4 of 6 MANAGER222S LAST TWO EMPLOYERS YEAR FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non-participation. Has anyone who is a party to this application, or 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, include traffic violations. Also list any charges pending at the time of this application. If more than one party, please list charges by each individual222s name. Commission must be notified of any arrests and/or convictions that may occur after the date of signing this application. YES NO If yes, please explain below or attach a separate page. Name of Applicant Date of Conviction (mm/yyyy) Where Convicted ( C ity & S tate) Description of Charge Disposition 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? YES NO IF YES, list the name of the premise(s): 3. Do you, as a manager, qualify under Nebraska Liquor Control Act (24753-131.01) and do you intend to supervise, in person, the management of the business? YES NO American LegalNet, Inc. www.FormsWorkFlow.com Form 103 Rev Jan 2018 Page 5 of 6 4. List the alcohol related training and/or experience (when and where) of the person making application. *NLCC Training Certificate Issued: Name on Certificate: Applicant Name Date (mm/yyyy) Name of program (attach copy of course completion certificate) *For list of NLCC Certified Training Programs see training Experience: Applicant Name / Job Title Date of Employment: Name & Location of Business: 5. Have you enclosed form 147 regarding fingerprints? YES NO American LegalNet, Inc. www.FormsWorkFlow.com Form 103 Rev Jan 2018 Page 6 of 6 PERSONAL OATH AND CONSENT OF INVESTIGATION The above individual(s), being first duly sworn upon oath, deposes and states that the undersigned is the applicant and/or spouse of applicant who makes the above and foregoing application that said application has been read and that the contents thereof and all statements contained therein are true. If any false statement is made in any part of this application, the applicant(s) shall be deemed guilty of perjury and subject to penalties provided by law. (Sec 24753-131.01) Nebraska Liquor Control Act. The undersigned applicant hereby consents to an investigation of his/her background including all records of every kind and description including police records, tax records (State and Federal), and bank or lending institution records, and said applicant and spouse waive any rights or causes of action that said applicant or spouse may have against the Nebraska Liquor Control Commission and any other individual disclosing or releasing said information to the Nebraska Liquor Control Commission. If spouse has NO interest directly or indirectly, a spousal affidavit of non-participation may be attached. The undersigned understand and acknowledge that any license issued, based on the information submitted in this application, is subject to cancellation if the information contained herein is incomplete, inaccurate, or fraudulent. 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. Signature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebraska County of The foregoing instrument was acknowledged before me this by date NAME OF PERSON BEING ACKNOWLEDGED Notary Public signature In compliance with the ADA, this application is available in other formats for persons with disabilities. A ten day advance period is required in writing to produce the alternate format. Affi