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APPLICATION FOR LIQUOR LICENSE <br /> k INDIVIDUAL Office U8e <br /> INSERT-FORM 1 RECEIVED <br /> F <br /> NEBRASKA LIQUOR CONTROL COMMISSION ' ECEIVED <br /> 301 CENTENNIAL MALL SOUTH <br /> PO BOX 95046 1 LINCOLN,NE 68509-5046 J 1-L 1 6 2018 <br /> PHONE:(402)471.2571 <br /> FAX (402)471.2814 <br /> Website: www.Icc.nebraska.gov NNEB�R�ASKA LIQUOR <br /> nN <br /> Individual applicants,including spouse, are required to adhered the mowinng requirements <br /> 1) Must be a citizen of the United States <br /> 2) Must be a Nebraska resident(Chapter 2-006) <br /> 3) Must provide a copy of their certified birth certificate,INS papers or US Passport <br /> 4) Fingerprints are required.See Form 147 for further information,this form MUST be included <br /> with your application <br /> 5) Must sign the signature page of the Application for License form <br /> 6) Applicant may be required to take a training course <br /> 7) Be a registered voter in the State of Nebraska,include a copy of voter registration card with <br /> application <br /> e 9. Ina d alfrailiclnti ito iv.;i` ,400 _4'01?":. <br /> Last Name:l%k ec k <br /> First Name: N1icka,2/ MI: Fran 2 <br /> Home Address: S-S3.2 totes,- S*/k y Perk RIM d,City: IQ fo(&c.. Zip Code: a 6 pro <br /> Social Security Number: 5D7- /3-3/3C Date of Birth: 1 c..z / 9'11` 4'99/ <br /> Home Telephone Number: 30 S. 381 - 1411 L CCU- 3t&-3'o . 7tOt <br /> Driver's License Number: &0 8 0 2/080 State: � <br /> 1 <br /> , .'1A� ay P.aS�0.,7, �f ;pir1sAS�s( ii�.1Tt inli to [sfUar E, v�y,r' ids -its 7��JY1.< n.Pm �.t.i., , ti <br /> . 1 WQC1 tqb is 41q _' `' ' I , `., <br /> EYES ONO If yes,provide your spouse's information below <br /> Spouses Last Name: <br /> Spouses First Name: MI: <br /> Social Security Number: Date of Birth: <br /> Driver's License Number: State: <br /> Form 104 <br /> REV JUNE 2015 <br /> Pagel <br />