Form 50g - Schedule Iii - Nebraska Schedule Iii County/city Lottery Worker Application
Download a blank fillable Form 50g - Schedule Iii - Nebraska Schedule Iii County/city Lottery Worker Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 50g - Schedule Iii - Nebraska Schedule Iii County/city Lottery Worker Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2NeBrasKa scheDUle III
ForM 50G
county/city lottery Worker application
RESET FORM
schedule III
• Incomplete applications will be returned.
Please Do Not Write iN this sPace
1
Nebraska I.D. Number of County, City, or Village
2
County, City, or Village Name as Shown on Form 50G
LOTTERY WORKER INFORMATION
Your social security number and date of birth are required under the Nebraska County and City Lottery Act and will be used to request criminal history
information from law enforcement agencies to determine if the legal requirements for a lottery worker’s license are met.
4 Date of Birth
3
Social Security Number
5 Type of Application
New
Inactive
Report Changes
Renewal
Cancel
DOR USE ONLY
Name (Last name, first name, middle name)
DOB Check
Aliases, Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise
Y
N
Street or Other Mailing Address
Date
City
State
Zip Code
County
6 Provide a brief description of your duties as a county/city lottery worker by checking the boxes that apply to you.
REQUIRED TO BE FINGERPRINTED (see 6a and 6b)
Authorized Representative
Security
Accounting
Keno Writer
Keno Manager
Governing Official
Other (specify)
Administration
Lottery Operator Officer or Owner
Individual other than keno manager who has
authority over verification of winning number
Audit
Keno Runner
Sales Outlet Officer or Owner
selection by a manual or automated ball draw device
6a 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?
NO
YES
If Yes, indicate the approximate date you were fingerprinted and the type of license involved.
Date:
Type of License:
6b Have you ever been fingerprinted by the Nebraska Liquor Control Commission in conjunction with an application for a liquor license?
NO
YES
If Yes, indicate the approximate date you were fingerprinted and the number of the liquor license. Date:
If you answered No to lines 6a and 6b, see the Instructions on the reverse side of this application.
Liquor License Number:
• You must answer questions 7 through 9 accurately.
7 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.)
If you answered Yes, see the Instructions on the reverse side of this application.
NO
YES
8 Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any other felony within ten years preceding the date of this application?
If you answered Yes, see the Instructions on the reverse side of this application.
NO
YES
9 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 as follows:
,
and I agree to provide a copy of my USCIS documentation upon request.
LOTTERY OPERATOR INFORMATION (Required unless working at a county, city, or village location.)
10 Nebraska Identification Number
Name, Address, City, State, Zip Code
LOTTERY SALES OUTLET LOCATION INFORMATION (Required if working at a sales outlet location.)
11 Nebraska Identification Number
Name, Address, City, State, Zip Code
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct. I hereby
attest that my response and the information provided in Line 9 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 the provisions of the Nebraska
sign
County and City Lottery Act and the regulations adopted under this Act.
here
Daytime Telephone Number
Date
Signature of Applicant
AUTHORIZATION – Signature of Governing Official or Authorized Representative
sign
I declare that I have examined this application and authorize the applicant to submit it to the Nebraska Department of Revenue for approval.
here
Signature of Governing Official or Authorized Representative
Title
Date
Daytime Telephone Number
Printed Name of Official or Representative
E-Mail Address
Mail this application to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, P.O. BOX 94855, LINCOLN, NE 68509-4855
12-2009
9-133-1993 Rev.
Supersedes 9-133-1993 Rev. 2-2008
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial