Form 50d - Nebraska Application For Pickle Card Operator Page 2
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612 Does anyone else not listed in line 7 have an ownership interest in the business named in this application? (See instructions.)
If Yes, indicate the Full Name, Home Address, Social Security Number, Date of Birth, and Title of the individuals involved and the nature of their interest.
YES
NO
13 Name of Person to Contact Regarding This Application:
Name
Title
Daytime Telephone Number
E-Mail Address
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 Pickle Card Lottery Act and the regulations adopted under such Act.
Home
sign
Work
here
Signature of Owner, Partner, Officer or member
Title
Date
Telephone Numbers
listed in line 7, or Person Authorized by Attached
Power of Attorney
E-Mail Address
Mail the original application and $100 fee to:
nebraska dePartment OF revenue, charitable gaming divisiOn, P.O. bOX 94855, lincOln, ne 68509-4855
Please make a cOPy FOr yOur recOrds.
instructiOns
whO must File. Any sole proprietorship, partnership, corporation, limited liability company, or nonprofit
organization that wants to sell individual pickle cards on behalf of an organization licensed to conduct a lottery
by the sale of pickle cards in Nebraska must apply for and obtain a pickle card operator’s license.
eligibility criteria. To qualify for a pickle card operator’s license, the applicant must hold a retail license
for the sale of alcoholic liquor for consumption on the premises or a retail license for the sale of alcoholic liquor
for consumption off the premises issued by the Nebraska Liquor Control Commission.
when and where tO File. A business which has not been previously licensed, may submit the application
at any time during the licensing period. All pickle card operator licenses expire on September 30 of each odd-
numbered year and may be renewed biennially. All applications for license renewal must be submitted at least
60 days prior to the expiration date of the license. License fees are due in full for the biennial licensing period.
However, if a new license application is received by the Nebraska Department of Revenue (Department) and the
license will become effective on or after October 1 of the second year of the biennial licensing period, the license
fee to be remitted to the Department is one-half of the biennial fee. Checks written to the Nebraska Department
of Revenue may be presented electronically.
The license application and fee are to be mailed to the Nebraska Department of Revenue, Charitable Gaming
Division, P.O. Box 94855, Lincoln, Nebraska 68509-4855. File the original application and not a photocopy.
Please make a copy of the application for your records.
This license application may also be used during the licensing period to report changes in the application
information originally submitted or to cancel the license. If requesting cancellation of the license, please include
the original license certificate issued by the Department.
scOPe OF Pickle card OPeratOr’s license. The pickle card operator’s license is valid for the
business in whose name it was issued, including all employees and agents of the business at that location. A pickle
card operator’s license may not be transferred under any circumstances, including change of ownership.
sPeciFic instructiOns
business name and lOcatiOn address. Enter the name, trade name (if applicable), and location of
the business or organization applying for the pickle card operator’s license. The pickle card operator’s license is
valid only for the location indicated.
Nebraska Pickle Card Operator Information Guide Application, October 28, 2010, Page 5
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