Form 50a - Nebraska Application For Manufacturers, Distributors, And Manufacturer-Distributors Of Bingo Equipment, Pickle Cards, Or County/city Lottery Equipment

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Nebraska Application for Manufacturers, Distributors, and Manufacturer-Distributors
Form 50A
of Bingo Equipment, Pickle Cards, or County/City Lottery Equipment
Page 1
1 Do you hold or have you previously held a Nebraska ID Number?
Please Do Not Write in This Space
Yes
No
If Yes, provide the number________________________________________.
PRINT FORM
RESET FORM
2 Federal Employer ID or Social Security Number
3 County of Business Location in Nebraska
Business Name and Location Address
Business Name and Mailing Address
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
5 Type of Application
6 Type of Ownership
4 Type of License
Domesticated Corporation
New
Sole Proprietorship
Distributor — Bingo/Pickle Card, $3,050 Biennial License Fee
Limited Liability Company (LLC)
Renewal
Manufacturer — Bingo/Pickle Card, $3,050 Biennial License Fee
Partnership
Other _____________________
Report Changes
Domestic Corporation
Manufacturer-Distributor County/City Lottery Supplies and/or
Equipment, $1,525 Biennial License Fee
Cancel
Foreign Corporation
7 If the applicant is a corporation or LLC, under laws of
8 For noncorporate out-of-state applicants, designate an individual at least 19 years of age, who is a resident of,
what state has it been incorporated or formed?
and living in, Nebraska as a resident agent.
Name
Phone Number
(
)
All foreign corporations and LLCs must be registered
Street or Other Mailing Address
with the Secretary of State’s Office. Attach a copy of
the document verifying registration with the
Nebraska Secretary of State’s Office.
City
State
Zip Code
9 If the applicant is a corporation, is it a publicly traded corporation?
Yes
No
Each applicant for a license as a manufacturer, distributor, or manufacturer-distributor is subject to a background investigation and/or an inspection
of its facilities. The Department may require the applicant to pay the actual costs incurred in conducting an investigation or inspection.
10 List the Social Security number, full name, home address, and date of birth for each of the following persons involved with the business named in this application:
a. If a sole proprietorship, list the individual owner;
b. If a partnership, list each partner and spouse;
c. If a LLC, list each member and spouse; or
d. If a corporation, list each officer and spouse and each person or entity holding 10% or more of the debt or equity of the applicant corporation. If any entity holding 10% or more of
the debt or equity of the applicant corporation is a partnership, LLC, or corporation, list each partner of the partnership, each member of the LLC, or each officer of the corporation
and every person or entity holding 10% or more of the debt or equity of that partnership, LLC, or corporation (attach a list if more space is required).
Social Security Number
Name, Address, City, State, Zip Code
Date of Birth Type of Involvement and Percentage of Ownership
11 If the applicant is a corporation, list the Social Security number, full name, home address, and date of birth for each director or board member.
Social Security Number
Name, Address, City, State, Zip Code
Date of Birth
Disclosure of the Social Security number and date of birth of individuals is required and authorized under the
Nebraska Bingo
Act, the
Nebraska Pickle Card Lottery
Act, and
the
Nebraska County and City Lottery
Act, and may be used to request criminal history information from law enforcement agencies to determine whether the applicant meets
the legal requirements for obtaining a license as a manufacturer, distributor, or manufacturer-distributor.
12 Has each individual listed in sections 10 and 11 above complied with the
Instructions for Completing Fingerprint
Application, or when applicable, filed a signed
Affidavit by Spouse
for Waiver
Form?
(See “What Must be Filed” instructions.)
Yes
No
13 Has each individual listed in sections 10 and 11 above completed and filed a
Personal History Record and Background Disclosure
Form, or when applicable, filed a signed
Affidavit by Spouse for Waiver
Form?
(See “What Must be Filed” instructions.)
Yes
No
14 Does the applicant business have offices, warehouses, or other outlets or facilities in addition to the location address listed above where gaming equipment and/or supplies are
stored, sold, or manufactured?
Yes
No
If Yes, attach a list identifying the complete name, address, and phone number of each location.
12-2013
9-036-1987 Rev.
Supersedes 9-036-1987 Rev. 6-2011

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