UPDATE RETAIL LICENSE INFORMATION CHANGE IN MANAGER Has there been a change in Manager: Yes______ No_____ If so, complete application for corporate manager change form 103, forms can be found on our web site: http://www.lcc.ne.gov/formsdiv.html CHANGE IN "MAIL TO" ADDRESS; where you wish notice, information and forms mailed. ________________________________________________________________ ________________________________________________________________ Name, Street Address, City, State, Zip Code CHANGE IN NONPROFIT OFFICERS Please attach a current list of new officers with this renewal. CHANGE IN PREMISES INFORMATION Premises name (doing business as)__________________________________________________________________ Premises phone number ____________________________________ CHANGE IN CORPORATE OR LLC INFORMATION Has there been a change in Corporate Officer(s): Yes______ No_____ If so, complete affidavit of corporate change form 117 or affidavit of Limited Liability Company (LLC) members form 118, forms can be found on our web site: http://www.lcc.ne.gov/formsdiv.html Change in corporation or LLC Phone number ______________________________________________________________________________________________ CHANGE IN LICENSEE STATUS: Has anyone listed on this renewal form; 1. Changed marital status 2. Passed away If yes, please indicate which individuals have had status changes and supply a phone number for the NLCC to call and discuss the appropriate paperwork that will be needed to be submitted. Any criminal convictions within the last year or pending charges (except minor traffic violations): Name of Licensee Date of Conviction (month/year) Where Convicted ( city & state) Description of Charge Disposition If more space is needed please attach a separate sheet of paper Please complete and fax back to (402) 471-2814 attention Mary or email to mary.messman@nebrasksa.gov FORM 138 REV JULY 2015 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com