Form 105 - Application For Liquor License Partnership Insert - Form 2 - 2015
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1
2APPLICATION FOR LIQUOR LICENSE
Office Use
PARTNERSHIP
INSERT – FORM 2
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN, NE 68509-5046
PHONE: (402) 471-2571
FAX: (402) 471-2814
Website:
Partner(s), including spouses, are required to adhere to the following requirements
1) Must be a citizen of the United States
2) At least one (1) partner must be a Nebraska resident (Chapter 2 – 006)
3) Must provide a copy of their certified birth certificate, INS papers or US Passport
4) Fingerprints are required. See Form 147 for further information, this form MUST be included
with your application
5) Must sign the signature page of the Application for License form
6) Primary Partner may be required to take a training course
7) Be a registered voter in the State of Nebraska, include a copy of voter registration card with
application
Name of Primary Partner (Please note if your partnership is a husband/wife combination then opposite spouse
will need to complete the additional partner section on the next page)
Last Name:________________________________________________________________________________
First Name:_______________________________________________________ MI:______________________
Home Address:_______________________________ City:___________________ Zip Code:______________
Social Security Number:_______________________________ Date of Birth:___________________________
Home Telephone Number:____________________________________________________________________
Driver’s License Number: _________________________________________ State:______________________
Are you married? (Please note if the above listed individual is separated, etc. spouse’s information is still
required to be listed below)
YES
NO
If yes, provide your spouse’s information below
Spouses Last Name: _________________________________________________________________________
Spouses First Name:________________________________________________ MI:_____________________
Social Security Number:_______________________________ Date of Birth:___________________________
Driver’s License Number: _______________________________________ State:________________________
Form 105
REV JUNE 2015
Page 1 of 2
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