Form 50a - Nebraska Application For Manufacturers, Distributors, And Manufacturer-Distributors Of Bingo Equipment, Pickle Cards, Or County/city Lottery Equipment Page 2
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4Nebraska Application for Manufacturers, Distributors, and Manufacturer-Distributors
Form 50A
of Bingo Equipment, Pickle Cards, or County/City Lottery Equipment
Page 2
15 Does the applicant business have employees actively engaged in the marketing of gaming supplies and/or equipment in Nebraska?
Yes
No
If Yes, attach a list identifying the name, home address, and phone number of each of these employees.
16 Does the applicant business currently hold any type of gaming-related license in any other state?
Yes
No
If Yes, attach a list identifying each state and the type of licenses held.
17 Has the applicant business ever been denied a gaming-related license in any state or had these licenses canceled, suspended, or revoked?
Yes
No
If Yes, attach a list identifying the state, the license actions taken, and the dates of these actions.
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 will comply with all of the provisions of the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, and the Nebraska County and City Lottery
Act, and the regulations adopted under these Acts.
sign
(
)
here
Signature of Owner, Partner, Officer, Member, or
Title
Date
Phone Number
Person Authorized by Attached Power of Attorney
Email Address
Mail original application, forms, and fees to:
Nebraska Department of Revenue, Charitable Gaming Division, PO Box 94855, Lincoln, NE 68509-4855.
revenue.nebraska.gov/gaming, 877-564-1315, or 402-471-5937
Instructions
Who Must File. Any person or business who wants to become: (1) a licensed distributor* of bingo equipment or pickle card units
in Nebraska; (2) a licensed manu facturer of bingo equipment or pickle card units in Nebraska; or (3) a licensed manufacturer-
distributor of county/city lottery supplies and/or equipment in Nebraska, must file a Nebraska Application for Manufacturers,
Distributors, and Manufacturer-Distributors, Form 50A.
*To be eligible for a distributor’s license, the applicant must have its principal office located in Nebraska.
What Must be Filed. Any person or business seeking a license as a manufacturer, distributor, or manufacturer-distributor must
complete and submit a Form 50A to the Department.
Neb. Rev. Stat. 9-1,104
requires certain applicants to be fingerprinted
Fingerprints and Background Check Waiver Form.
for criminal background investigation purposes. Please refer to the
Instructions for Completing Fingerprint Application
to determine
who is subject to this requirement and whether any exceptions may apply. Each individual required to be fingerprinted must also
Background Check Waiver Form
and the proper fees.
submit to the Department, a
Additional Attachments Required. If the applicant is a partnership, provide a copy of the partnership agreement. If the applicant
is a corporation, provide a copy of the articles of incorporation and all amendments. If the applicant is a LLC, provide a copy of
the articles of organization.
(Disclosure Form). Each person required to be fingerprinted
Personal History Record and Background Disclosure Form
must also complete and submit a Disclosure Form. The filing of a Disclosure Form can be waived for a spouse if the spouse files
Affidavit by Spouse for Waiver of Fingerprinting and/or Personal History Record and Background Disclosure Form
an
indicating
they will have no interest, directly or indirectly, in the operation or profit of the business.
For purposes of the Disclosure Form and fingerprinting requirements, a “person or entity” is a debt holder of a corporation or
partnership if the person or entity holds any mortgages, notes, bonds, convertible debentures, or other obligations, whether written
or oral, issued by the corporation or partnership. For purposes of this form, a “debt holder” does not include any financial institution
organized or chartered under the laws of Nebraska, any other state, or the United States relating to banks, savings institutions, trust
companies, savings and loan associations, credit unions, installment loan licensees, or similar associations organized under the laws
of Nebraska and subject to supervision by the Department of Banking and Finance. A person or entity is an “equity holder of the
corporation or partnership” if the person or entity holds any capital stock, whether common or preferred, issued by the corporation
or partnership.
When and Where to File. Licenses issued to manufacturers and distributors of bingo equipment, pickle card units, and licenses
issued to manufacturer-distributors of county/city lottery supplies and/or equipment expire on September 30 of every odd-numbered
year and may be renewed biennially. License renewal applications must be submitted to the Department at least 45 days prior to the
expiration date of the license.
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