Form 50 - Nebraska Schedule Ii - Authorization For Pickle Card Operators

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NEBRASKA SCHEDULE
II
— Authorization for Pickle Card Operators
FORM 50
• No fee required.
Schedule II
• Incomplete applications will be returned.
PLEASE DO NOT WRITE IN THIS SPACE
1 Licensed Organization’s Name
RESET FORM
PRINT FORM
2 Nebraska ID Number of Licensed Organization
Before an organization may file a Nebraska Schedule II to authorize a business to sell its pickle cards, the business must
have obtained or applied for a pickle card operator’s license. To obtain a pickle card operator’s license, the business
must file a Nebraska Application for Pickle Card Operator, Form 50D, and submit a $100 fee. No pickle cards may be
sold by a business until it has physical possession of both a pickle card operator’s license and an authorization from the
organization for which it intends to sell individual pickle cards.
PICKLE CARD OPERATOR
Type of Application
Trade Name of Business
New
Renewal
Street Address
Report Changes
Cancel (Attach Authorization
Issued to Pickle Card Operator.)
City
Zip Code
County
State
Nebraska ID Number
I declare that I have examined this application and agree to sell pickle cards on behalf of the licensed organization named above.
sign
here
Signature of Owner, Partner, Member, Officer of Pickle Card
Title
Date
Daytime Telephone Number
Operator, or Person Authorized by Attached Power of Attorney
Email Address
LICENSED ORGANIZATION AUTHORIZATION—Signature of Utilization of Funds Member
I declare that I have examined this application and approve the pickle card operator named in this application to sell pickle cards on our behalf.
sign
here
Signature of Utilization of Funds Member of Licensed Organization
Date
Daytime Telephone Number
Email Address
INSTRUCTIONS
WHO MUST FILE. Any nonprofit organization or volunteer fire company or volunteer first-aid, rescue,
ambulance, or emergency squad licensed to conduct a lottery by the sale of pickle cards on the premises of one
or more licensed pickle card operators (Class II licensee) must complete and submit the Nebraska Schedule II
to author ize a licensed pickle card operator to sell individual pickle cards on its behalf. Before any licensed
organization can authorize a business to sell its pickle cards, the business must obtain, from the Nebraska
Department of Revenue (Department), a pickle card operator’s license using
Nebraska Application for Pickle
Card Operator, Form
50D.
The authorizations for pickle card operators are mailed to the licensed organization. The licensed
organization is required to distribute the authorizations to the proper pickle card operators.
A pickle card operator may not sell individual pickle cards on behalf of any licensed organization until the
organization has received an authorization from the Department entitling that pickle card operator to sell
individual pickle cards on its behalf. A pickle card operator’s license alone is not enough to allow a business to
sell individual pickle cards. A business must have physical possession of both a pickle card operator’s license and
an authorization issued by the Department before it may sell pickle cards. An authorization is required for each
licensed organization for which the pickle card operator intends to sell pickle cards.
Mail the original application to:
NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, PO BOX 94855, LINCOLN, NE 68509-4855
6-2011
RETAIN A COPY FOR YOUR RECORDS.
9-035-1987 Rev.
Supersedes 9-035-1987 Rev. 4-2009

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