Form 101 - Application For Liquor License Corporation Insert - Form 3a - 2015
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1
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4APPLICATION FOR LIQUOR LICENSE
Office Use
CORPORATION
INSERT - FORM 3a
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN, NE 68509-5046
PHONE: (402) 471-2571
FAX: (402) 471-2814
Website:
Officers, directors and stockholders holding over 25% shares of stock, including spouses, are required to adhere to the following
requirements:
1) All officers, directors and stockholders must be listed
2) President/CEO and stockholders holding over 25% and their spouse(s) (if applicable) must submit fingerprints. See Form
147 for further information, this form MUST be included with your application.
3) Officers, directors and stockholders holding over 25 % shares of stock and their spouse (if applicable) must sign the
signature page of the Application for License Form 100 (even if a spousal affidavit has been submitted)
Attach copy of Articles of Incorporation (must show electronic stamp or barcode receipt by Secretary of States Office)
Name of Registered Agent:____________________________________________________________________________
Name of Corporation that will hold license as listed on the Articles
__________________________________________________________________________________________________
Corporation Address:________________________________________________________________________________
City:_______________________________________ State:___________________ Zip Code:______________________
Corporation Phone Number: ____________________________Fax Number____________________________________
Total Number of Corporation Shares Issued:______________________________________________________________
Name and notarized signature of President/CEO (Information of president must be listed on following page)
Last Name:____________________________________ First Name:___________________________ MI:____________
Home Address:_____________________________________________ City:____________________________________
State:____________________ Zip Code:__________________ Home Phone Number:____________________________
___________________________________________________________________________________________
Signature of President/CEO
ACKNOWLEDGEMENT
State of Nebraska
County of ____________________________________________ The foregoing instrument was acknowledged before me this
_____________________________________________________ by ______________________________________________________
Date
name of person acknowledge
Affix Seal
____________________________________________________
FORM 101
REV JUNE 2015
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