Form 115 - Alcoholic Liquor Tax Bond - 2016 Page 2
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2This Bond shall be effective during all proceedings involving the application for license under the Nebraska Liquor
Control Act for Alcoholic Liquor and/or Beer license and upon issuance of said license this Bond shall continue
until cancelled as set forth hereinabove.
This Bond has been given Bond number ______________________________________________________.
PRINCIPAL
SURETY COMPANY
IN TESTIMONY, WHEREOF, said PRINCIPAL has
IN TESTIMONY, WHEREOF, said SURETY has
hereunto subscribed his or their names or has caused this
caused this instrument to be signed by its duly
instrument to be signed by its duly authorized officer this
authorized office and its corporate seal to be hereunto
date: ________________________A.D. 20_________
affixed this date:
______________________________A.D. 20 ______
____________________________________________
_________________________________________
SIGNATURE
SIGNATURE for Attorney-in-Fact FOR Surety Company
____________________________________________________________
__________________________________________________________
PRINT NAME HERE
PRINT NAME HERE
___________________________________________________________
__________________________________________________________
WITNESS SIGNATURE
SURETY COMPANY NAME
___________________________________________________________
__________________________________________________________
PRINT NAME HERE
SURETY COMPANY MAILING ADDRESS
___________________________________________________________
SURETY COMPANY AREA CODE AND PHONE NUMBER
____________________________________________________________
INSURANCE PRODUCER’S AREA CODE AND PHONE NUMBER
NOTICE
Bond will not be accepted unless properly signed by applicant, whose signature shall be witnessed. It is also
necessary that all Bonds be signed by an official or agent of the Bonding Company who holds and unexpired
power-of-attorney from the Bonding Company and unexpired Nebraska liquor license as insurance producer for
said company. An additional requirement is attachment of the seal of the Bonding Company and, if applicant is a
corporation, their seal should also be attached.
Page 2 of 2
REV APRIL 2016
FORM 115
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