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PRIVACY ACT STATEMENT/ Office Use only <br /> SUBMISSION OF FINGERPRINTS / <br /> PAYMENT OF FEES TO NSP-CID RECEIVED <br /> NEBRASKA LIQUOR CONTROL COMMISSION JUL 1 6 2018 <br /> 301 CENTENNIAL MALL SOUTH <br /> PO BOX 95046 NEBRASKA LIQUOR <br /> LINCOLN,NE 68509-5046 <br /> PHONE: (402)471-2571 <br /> FAX: (402)471-2814 <br /> Website: www.lcc.nebraska.gov <br /> THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED: <br /> DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: <br /> • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED FEE TO THE <br /> NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIOUOR LICENSE <br /> • Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol; <br /> It is recommended to make payment through the NSP PayPort online system at www.ne.gov/go/nsa <br /> Or a check made payable to NSP can be mailed directly to the following address: <br /> ***Please indicate on your payment who the payment is for(the name of the person being <br /> fingerprinted)and the ayment is for a Liquor License*** <br /> The Nebraska State Patrol—CID Division <br /> 3800 NW 12th Street <br /> Lincoln,NE 68521 <br /> • Fingerprints taken at NSP LIVESCAN locations will be forwarded to NSP—CID <br /> Applicant(s) will not have cards to include with license application. <br /> • Fingerprints taken at local law enforcement offices may be released to the applicants; <br /> Fingerprint cards should be submitted with the application. <br /> Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history <br /> records of the FBI. You have the opportunity to complete or challenge the accuracy of the information <br /> contained in FBI identification record. The procedures for obtaining a change, correction, or updating a <br /> FBI identification record are set forth in Title 28, CFR, 16.34. <br /> Trade Name: Fo4rler Ui ew 4o/1 <br /> Name of Person Bring Fingerprinted: /b" 4.as/ Fran 2 lot etX <br /> Date of Birth:01./n4 47( Last 4 SSN: y1 35' Date fingerprints were taken:lj ja /a w` ?o/r <br /> Location where fingerprints were taken: !'coop C. i A 5 (a h.c J '4 h d <br /> How was payment made to NSP? <br /> ❑NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK# <br /> My fingerprints are already on file with the commission—fingerprints completed for a previous <br /> application less than 2 years ago? YES ❑ <br /> L.o ., ti <br /> SIGNATURE REQID 0 PERSON BEING FINGERPRINTED <br /> FORM 147 <br /> REV MAY 2018 <br />