Form 50d - Nebraska Application For Pickle Card Operator

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nebraska application for Pickle card Operator

FOrm

• Include $100 license fee.

50d

• Incomplete applications will be returned.

2 Federal Employer ID Number or

1 Do you hold or have you previously held a Nebraska

Please dO nOt write in this sPace

Identification Number?

Social Security Number

RESET FORM

YES

If yes, give number

3 County of Business Location

4 Type of Application

in Nebraska

New

Renewal

Report Changes

Cancel (Please enclose license.)

business name and lOcatiOn address

business name and mailing address

Name

Trade Name of Business (If Different Than Above)

Street or Other Mailing Address

Street Address

City

State

Zip Code

City

State

Zip Code

5 Type of Ownership

Domestic Corporation

Foreign Corporation

Sole Proprietorship

Limited Liability Company

Domesticated Corporation

Nonprofit Corporation or Organization

Partnership

Other:

6 Liquor License Information

Class of Liquor License:

Liquor License Number:

a. If purchasing an existing business, have you applied for a Temporary Operating Permit and filed a Liquor License Application with the Nebraska Liquor Control Commission?

YES

b. Description of premises covered by liquor license (Attach additional sheet if necessary.):

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 pickle card operator’s license are met.

7 Ownership Information:

List the Social Security number, full name, home address, date of birth, type of involvement, and percentage of ownership for each of the following persons involved with the applicant:

a. If a sole proprietorship, list the individual owner.

b. If a partnership, list each partner and spouse.

c. If a corporation, list each officer and spouse and each person holding ten percent or more of the debt or equity of the applicant corporation. If any person holding 10 percent

or more of the debt or equity of the applicant corporation is a partnership, limited liability company, or corporation, list each partner of such partnership, each member of such

limited liability company, or each officer of such corporation and every person holding ten percent or more of the debt or equity of any such partnership, limited liability

company or corporation.

d. If a limited liability company, list each member and spouse.

e. If a nonprofit organization or nonprofit corporation, list each officer and the person designated as manager.

(Attach additional sheet if necessary.)

Type of Involvement and

Social Security Number

Name, Address, City, State, Zip Code

Date of Birth

Percentage of Ownership

8 Does any individual listed in line 7 have any interest, directly or indirectly, with any distributor or manufacturer of pickle card units licensed in Nebraska?

YES

If Yes, attach a detailed explanation of the individuals involved and the nature of these interests.

9 Is anyone listed in line 7 licensed as a sales agent or utilization of funds member of an organization licensed to conduct a lottery by the sale of pickle cards in Nebraska?

YES

If Yes, attach a list of the names of the individuals and the corresponding licensed organizations involved.

10 Is anyone listed in line 7 a director, manager, trustee, or member of the governing committee, board, or body of the licensed organization

for which you will be selling pickle cards?

YES

If Yes, attach a list of the names and responsibilities of the individuals and the corresponding licensed organizations involved.

11a Has anyone listed in line 7 ever been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony or misdemeanor at any time involving any

gambling activity or fraud, theft, willful failure to make required payments or reports, or filing false reports with a government agency at any level? (This includes shoplifting

or issuing bad checks.)

YES

If Yes, see instructions.

11b Has anyone listed in line 7 ever 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 Yes, see instructions.

YES

(cOntinued On the reverse side.)

Nebraska Pickle Card Operator Information Guide Application, October 28, 2010, Page 4