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NEBRASKA LIQUOR CONTROL COMMISSION <br /> PHONE:(402)471-2571 <br /> Website• www.Icc.nebraska.gov <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 /> P71)0 4+mo- xun /7)UY&O L The <br /> Retail Liquor License Name or*Non-Profit Organization(*Must include Form#201 as Page 2) <br /> HA if,. (4-11,6t . f.& L 14CYCZ3. <br /> Retail Liquor License Address or Non-Profit Business Address <br /> lli 09 <br /> Retail License Number or Non-Profit Federal ID# <br /> Consecutive Dates only <br /> Event Date(s): <br /> Event Start Time(s): Hamer <br /> Event End Time(s): <br /> Alternate Date: <br /> Alternate Location Building&Address: ,,1 <br /> Event Building Name: 6a I r 5 /9i 0gnb(� ;-� � '�` ` • J 11 <br /> Event Street Address/City: ( �� �t/• Loo �l l)k ( I C1 I hcd RI tie ✓� h� <br /> Indoor area to be licensed in length&width:I LCi X <br /> Outdoor area to be licensed in lenn�gt�h,,&width: X (Diagram Form#109 must be attached) <br /> Type of Event:OJiSIU it PRY CCJat(}� Estimate#of attendees: d,,C)(T) <br /> Type of alcohol to be served: Beer IV Wine ✓ Distilled Spirits <br /> f t� (If not marked,you will not be able to serve this t�ppeelof alcohol) 2 <br /> Event Contact Name:i.Q.ran(co. kl M( . Event Contact Phone Number:✓""/ 6" c�L <br /> Event Contact Email: jryiolio ei-0 R IY)0_.rIj2 t("'3rno 3 (er . <br /> f <br /> *Signature Authorized Representativy/ • / //t '1.I I Printed Name 9/Qf&Ilefic l na:St <br /> I declare that I am the authorized represen .rr+- of the above named license applicant and that the statements made on this application are true to the <br /> best of my knowledge and belief I also consent to an investigation of my background including all records of every kind including police records. I agree <br /> to waive any rights or causes of action against the Nebraska Liquor Control Commission,the Nebraska State Patrol or any other individual releasing <br /> said information to the Liquor Control Commission or the Nebraska State Patrol.I further declare that the license applied for will not be used by any <br /> other person,group,organization or corporation for profit or not for profit and that the event will be supervised by persons directly responsible to the <br /> holder of this Special Designated License. <br /> *Retail licensee-Must be signed by a member listed on permanent license <br /> *Non-Profit Organization—Must be signed by a Corporate Officer <br /> Local Governing Body completes below: 11 <br /> The local governing body : e 'ty/Village of County of 1-t c approves <br /> the issuance 4a. led: 1 esign • i License as requested above. (Only one should be written above) <br /> —L G -L <br /> ocal 'verning B I t Authorized Signature Date <br />