SUBMISSSION OF FINGERPRINTS /
DATE RECEIVED
PAYMENT OF FEES TO NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN, NE 68509-5046
Office Use Only
PHONE: (402) 471-2571
FAX: (402) 471-2814
Class:______
License #:_______________________
Website:
Applicant Name:
(Corporation, LLC, Partnership or Individual)
Trade Name:
(Doing Business As)
( )
-
Phone Number
Contact E-mail Address
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• See Application Requirement Guide for listing of Fingerprint Requirements, found on our
website
under
“Licensing” tab in “Guidelines / Brochures”. FAILURE TO FILE FINGERPRINT CARDS AND PAY
THE REQUIRED PROCESSING FEE TO THE NEBRASKA STATE PATROL WILL DELAY
THE ISSUANCE OF YOUR LIQUOR LICENSE.
• This completed form MUST be included with your Liquor License Application and/or Manager
Application or changes to: Corporate Officers or Stockholders, LLC Members, Partners or Addition of
Spouse where new fingerprint cards are required (see New Application Requirement Guide).
• DO NOT send fee payments to the NLCC – fees MUST be paid directly to NSP;
Include a list of names covered by your payment to insure proper application of payment.
• Fee payment of $28.75 per person must be made directly to the NSP;
It is recommended to make payment through the NSP PayPort online system at
Or checks made payable to NSP should be mailed directly to the following address:
The Nebraska State Patrol – CID Division
th
3800 NW 12
Street
Lincoln, NE 68521
• Fingerprints are not required for spouses that have no involvement with business - Spousal Affidavit of
Non Participation (Form 116) is required in lieu of fingerprints.
• Fingerprints taken at NSP locations will be forwarded to NSP – CID;
Applicant(s) will not have cards to include with license application.
• Fingerprints taken at local law enforcement offices will be released to the applicants;
Fingerprint cards should be submitted with the application.
Please complete information on the following pages for EACH person fingerprinted.
FORM 147
REV MAR 2016
PAGE 1