PetroMart 2 (S 19th)RENEW ON-LINE AT WWW.LCC.NE.GOV OR MAIL BY APRIL 15TH
Y
PREMISE
PETROMART2
454 S 19TH ST
BLAIR NE 68008 1908
(402)426-3303
BHANSEN@NEIASUPPLY.COM
CORPORATION INFORMATION
LIPPINCOTT, MARK T
LIPPINCOTT, MATT C
BROCHARDT, JOHN P
HANSEN, BRIAN L
TOTAL AMOUNT DUE
MAKE CHECKS PAYABLE TO
MAIL TO:
STATE OF NEBRASKA
LIQUOR CONTROL COMMISSION
RENEWAL REQUEST
LICENSE NUMBER
121998
D ALCOHOLIC LIQUOR OFF SALE
MAIL TO ADDRESS
NEBRASKA IOWA SUPPLY CO INC
PO BOX 368
BLAIR NE 68008
SHARES
PRESIDENT
SECRETARY
TRES/CFO
MANAGER
$45.00
LICENSEE
NIBS INC
1160 LINCOLN ST
BLAIR NE 68008 2163
NEBRASKA LIQUOR CONTROL COMMISSION
PO BOX 95046, LINCOLN NE 68509-5046
WE, THE UNDERSIGNED DO HEREBY AGREE TO BE BOUND BY ALL PROVISIONS OF THE NEBRASKA LIQUOR
CONTROL ACT. I, WE, FURTHER STIPULATE THAT THERE HAVE BEEN NO CHANGES SINCE THE ORIGINAL
APPLICATION WAS FILED WITH THE NEBRASKA LIQUOR CONTROL COMMISSION, NO CHANGES IN OWNERSHIP
HAVE BEEN MADE, THE PREMISES ARE CURRENTLY IN OPERATION AND ALL THE ABOVE INFORMATION IS TRUE
AND CORRECT AS FILED WITH THE NEBRASKA LIQUOR CONTROL COMMISSION.
SIGNATURE OF LICENSEE
PRINT NAME
FAILURE TO RENEW ON TIME WILL RESULT IN PENALTIES AND YOUR
ABILITY TO SELL ALCOHOL
LCC1 06113
AFFIDAVIT FOR UPDATING LIQUOR LICENSE INFORMATION
CHANGE IN MANAGER
Has there been a change in Manager: Yes No
If yes, complete corporate manager form 103 on our web site: http://www.icc.ne.gov/formsdiv.htmi
CHANGE IN "MAIL TO" ADDRESS: where you wish notice, information and forms mailed.
Name, Street Address, City, State, Zip Code
CHANGE IN NONPROFIT OFFICERS
Please attach a current list of new officers with this renewal.
CHANGE IN PREMISE INFORMATION
Premise name (doing business as)
Premise phone number.
CHANGE IN CORPORATE OR LLC INFORMATION
Has there been a change in Corporate Officer(s): Yes No
If yes, complete corporate change form 117 on our web site: h
Change in corporation of LLC Phone number
://www.Icc.ne.qov/formsdiv.html
If you are the holder of a Class C license do you intend to allow the sale of cocktails to go as allowed under Neb. Rev.
Stat. 53-123.04(4)? Yes No
If you are the holder of a Class I license do you intend to allow the sale of cocktails to go as allowed under Neb. Rev.
Stat, 53-123.04(5)? Yes No
If you are the holder of a Class Y license do you intend to allow the sale of cocktails to go as allowed under Neb. Rev.
Stat. 53-123.011(i)? Yes No
If you are the holder of a Class B, Class C, Class D, Class L, Class Y, or Class Z license do you intend to allow drive
through services under 53-178.01(2)? Yes No
CHANGE IN LICENSEE STATUS:
Has anyone listed on t is renewal form:
1. Changed marital status: Yes No
2. Passed away: Yes No
If yes, please indicate which individuals have had status changes and supply a phone number for the
NLCC to call and discuss the appropriate paperwork that will be needed to be submitted.
Any criminal convictions within the last year or pending charges (except minor traffic violations):
Name of Licensee
Date of
Conviction
(month/year)
Where Convicted
(city & state)
Description of
Charge
Disposition
If more space is needed please attach a separate sheet of paper.
LCC2 08121