Application For Deletion To Liquor License {112}

APPLICATION FOR DELETION TO LIQUOR LICENSE NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 Website: www.lcc.nebraska.gov Office Use Application: Must include processing fee of $45.00 checks made payable to Nebraska Liquor Control Commission (NLCC) or you may pay online at www.ne.gov/go/NLCCpayport Must include simple hand drawn sketch showing existing licensed area and area to be deleted, must include outside dimensions in feet (not square feet), and show direction north. NO BLUE PRINTS May include approval from the local governing body; no deletion shall be approved unless endorsed by the local governing body Check with your local governing body for any additional requirements that may be necessary in making this request for deletion LIQUOR LICENSE #__________________________________CLASS TYPE________________________ LICENSEE NAME________________________________________________________________________ TRADE NAME___________________________________________________________________________ PREMISE ADDRESS______________________________________________________________________ CITY_________________________ZIP CODE_______________COUNTY_________________________ CONTACT PERSON______________________________________________________________________ PHONE NUMBER OF CONTACT PERSON__________________________________________________ EMAIL ADDRESS OF CONTACT PERSON__________________________________________________ BARCODE LABEL FORM 112 REV APR 2015 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 1. What is being deleted? Explain why this area is being removed from licensed description _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 2. Include a sketch of the area to be deleted showing: existing licensed area with length & width in feet area to be deleted with length & width in feet direction north I acknowledge under oath that the premises as altered to comply in all respects with the requirements of the act. Neb Rev Stat §53-129 ________________________________________________ Signature of Licensee or Officer State of Nebraska County of _____________________________________ The foregoing instrument was acknowledged before me this __________________________________________ by __________________________________________________ Date name of person acknowledged (individual(s) signing document) Affix Seal __________________________________________ Notary Public signature FORM 112 REV APR 2015 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com