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NEJRASKA LIQUOR CONTROL COMMISSION <br /> - ' NbNE:(402}471-2571 <br /> Wetmore: WWW.ICC.nCbfaskLYOt <br /> Special Designated License <br /> Local Recommendation (Form 200) <br /> Applications must be entered on the portal after local approval—no exceptions <br /> Late applications are non-refundable and will be rejected <br /> Bct ) 2 1✓! C . <br /> Retail Liquor License Name or*Non-Profit Organization(*Must include Form#201 as Page 2) <br /> 3921 bleS4 s-Je 51ree4- <br /> Retail Liquor License Address or Non-Profit Business Address <br /> 391 `-fv G <br /> Retail License Number or Non-Profit Federal ID# <br /> Event Date(s): 5ep, 27, 2LVS <br /> Event Start Time(s): q E <br /> Event End Time(s): I 1 P rn <br /> Alternate Date: NONE <br /> Alternate Location Building& Address: No N E <br /> Event Building Name: Elea N-)anar , ,PA6 IL6ADa-rl4,- P`fk I <br /> Event Street Address/City: (p 7F8 Well- l-/USken/4AI y1 698g/0 /� I del <br /> Indoor area to be licensed in length&width: 17/6 X 70 <br /> Outdoor area to be licensed in length& width: X_(Diagram Form#109 must be attached) <br /> Type of Event: re C P D4 I o/1 Estimate#of attendees: /00 <br /> Type of alcohol to be served: Beer X Wine X Distilled Spirits X <br /> (If not marked,you will not be able to serve this type of alcohol) <br /> Event Contact Name: Sep{ R i cl,4 NISon Event Contact Phone Number: 3438—371- A792 <br /> Event Contact Email: j e e be I z5 pa r Fs ba>`, CD n <br /> *Signature Authorized Representative: 4,44 C , 'd. A A,, <br /> *Retail , - 11 ust be signed by a member listed on permanent license <br /> *Non-'rofit Organization—Must be signed by a Corporate Officer <br /> Local Governing Body completes below: <br /> The local governing body for the City of a County orictiti approves the <br /> /∎ of a�J int Design:- d Li a as requested above. <br /> l2, <br /> F+ I Gove rng Bod /Mho ' Signature Date <br />