SUPPLEMENTAL FORM FOR APPLICATION WITHIN 300' OF CAMPUS 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.ne.gov PROPOSED PREMISE INFORMATION Applicant name: ______________________________________________________________ Premise name: ________________________________________________________________ Premise address: ______________________________________________________________ City: ________________________________________________________________________ Type of business: ______________________________________________________________ Include a description of the justification for the waiver explaining how the proposed location complies with the findings listed: The impact of retail sales of alcoholic liquor for consumption on the premises on the academic mission of the college or university The impact on students and prospective students if such sales were permitted on or near campus The impact on economic development opportunities located within or in proximity to the campus CAMPUS INFORMATION Name of College/University: ________________________________________________ Address of College/University: ______________________________________________ City: ____________________________ County: ________________________________ DISTANCE FROM AFOREMENTIONED CAMPUS __________________ FEET Waiver will not be granted without written approval from the governing body of the college or university or its designee if the physical location of the property which is the subject of the requested waiver is (a) surrounded by property owned by the college or university including any public or private easement, street, or right-of-way adjacent to the property owned by the college or university or (b) adjacent to property on two or more sides owned by the college or university including any public or private easement, street, or right-of-way adjacent to the property owned by the college or university. FORM 135 REV JULY 2015 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com