SUPPLEMENTAL FORM FOR APPLICATION WITHIN 150' OF CHURCH NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH, 5TH FLOOR PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 Website: www.lcc.nebraska.gov Office Use �53-177(2) If a proposed location for the sale at retail of any alcoholic liquor is within 150' of any church, a license may be issued if the commission gives notice to the affected church and holds a hearing as prescribed in �53-133 PREMISE INFORMATION License number (if currently licensed) _________________________________ Premise Name: _____________________________________________________________________ Address: __________________________________________________________________________ City: ______________________________________________________________________________ CHURCH INFORMATION Name of Church: ____________________________________________________________________ Address of Church: __________________________________________________________________ CONTACT PERSON (if available) _____________________________________________________ Phone Number � (if available) __________________________________________________________ DISTANCE FROM AFOREMENTIONED CHURCH __________________ FEET (closest corner of licensed premise to closest corner of church) Neb Rev Stat �53-177 AMOUNT AND FREQUENCY OF SERVICES HELD AT CHURCH (if known) ________________________________________________________________________ ________________________________________________________________________ FORM 134 REV JULY 2015 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com