Form 50e - Nebraska Application For Pickle Card Sales Agent For Class Ii Licensed Organizations Only - 2001

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Nebraska Application for Pickle Card Sales Agent

Form

for Class

Licensed Organizations Only

50E

• License fee is $100.

• Incomplete applications will be returned.

1 Licensed Organization’s Name

Please Do Not Write in This Space

PRINT FORM

RESET FORM

2 Nebraska ID Number of Licensed

3 Type of Application

Organization

New

Report Changes

Renewal

Cancel (Return license)

Sales Agent Information (Attach additional sheet, if necessary.)

Social Security Number

Name

Street Address

Date of Birth

PO Box

City

State

Zip Code

County

Your Social Security number and date of birth are required under the Nebraska Pickle Card Lottery Act, and will be used to request criminal history

information from law enforcement agencies to determine if the legal requirements for a sales agent’s license are met.

4 Are you an active and bona fide member of the licensed organization named above?

Yes

If Yes, indicate the date (month/day/year) you became a member:

5 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a pickle card operator or as a manufacturer or distributor of bingo equipment and/or

pickle card units in Nebraska?

Yes

If Yes, provide detailed explanation:

6 Do you hold or have you previously held any other licenses issued under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, the Nebraska Lottery and Raffle Act, or

the Nebraska County and City Lottery Act?

Yes

If Yes, indicate the types of licenses and check current status:

Active

Suspended

Cancelled

Revoked

Expired

7a Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony or misdemeanor at any time involving fraud, theft, any gambling activity, willful

failure to make required payments or reports, or filing false reports with a governmental agency at any level? This includes shoplifting or issuing bad checks.

Yes

7b Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony other than those listed in 7a within the last 10 years?

Yes

If you answered Yes to 7a or 7b, indicate the date and place the incident occurred, the court case or docket number under which it is filed, the original charge or ultimate

disposition of the matter, and a description of the events which are the subject of the incident.

8 Are you a director, manager, trustee, or member of the governing committee, board or body of the licensed organization for which you will function as a sales agent?

Yes

If Yes, what is your responsibility?

9 Will you receive any commission, salary, fee, or other type of compensation from the licensed organization for functioning as a sales agent?

Yes

If Yes, explain the compensation which you will receive:

10 Have you ever been fingerprinted for a license under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, or the Nebraska County and City Lottery Act?

Yes

Type of License:

If Yes, indicate the approximate date you were fingerprinted and the type of license involved.

Date:

If No, see the instructions on the reverse side of this application.

1 1 For New Applicants Only. For the purpose of complying with

Neb. Rev. Stat. §§ 4-108 through

4-114, I attest as follows:

I am a citizen of the United States; or

I am a qualified alien under the federal Immigration and Nationality Act. My immigration status and alien number are:__________________________________, and I agree

to provide a copy of my USCIS documentation upon request.

Under penalties of law, I declare that I have examined this application and to the best of my knowledge and belief, it is correct and complete. I hereby attest that

my response and the information provided in line 12 and any related application for public benefits are true, complete, and accurate. I understand that this information

may be used to verify my lawful presence in the United States. I will comply with all of the provisions of the Nebraska Pickle Card Lottery Act and the regulations adopted

sign

under such Act.

here

(

)

Signature of Applicant

Date

Daytime Phone Number

Email Address

Licensed Organization Authorization — Signature of Utilization of Funds Member

sign

I declare that I have examined this application and approve the person to act as a sales agent on behalf of the above-named licensed organization.

(

)

here

Daytime Phone Number

Signature of Utilization of Funds Member

Date

For Cancellation Only — Release by Licensed Organization

We, the undersigned, do hereby release the above-named individual from his or her responsibility as a sales agent for the above-named licensed organization.

We further certify that the above-named individual has satisfied all legal obligations he or she has to the organization in connection with the organization's lottery by

sign

the sale of pickle card activity.

(

)

here

Signature of Utilization of Funds Member

Daytime Phone Number

Date

(

)

Signature of an Officer of the Organization

Title