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12. List the alcohol related training and/or experience(when and where)of the person(s)making application. Those persons <br /> required are listed as followed: <br /> • Individual: Applicant and spouse;spouse is exempt if they filed Form 116-Affidavit of Non-Participation. <br /> • Partnership: All partners and spouses,spouses are exempt if they filed Form 116-Affidavit of Non-Participation. <br /> • Limited Liability Company: All member of LLC,Manager and all spouses; spouses are exempt if they filed Form <br /> 116-Affidavit of Non-Participation. <br /> • Corporation: President,Stockholders holding 25%or more of shares,Manager and all spouses;spouses are exempt if <br /> they filed Form 116-Affidavit of Non-Participation. <br /> NLCC certified training program completed: <br /> Applicant Name Date Name of program(attach copy of course completion certificate) <br /> (�rtYY) <br /> f Vl ( i2.0 F2�z ti' (:39 Q. i e-k'b, <br /> (,() ; 2.t_,1L <br /> For list of NLCC certified training programs see: www.lcc.ne.gov/tmininginfo.html <br /> I Experience: r <br /> Applicant Name lob title Date of Name&Location of Business <br /> Employment: <br /> .n If <br /> a copy property he lease covering the entire licceense Doe copy of the <br /> show d tle oproof ease held in name of <br /> I <br /> a. .licant as owner or lessee in the indivi. I r ; . Ira . . 1 ... application is being filed. <br /> hi Lease:expiration date 1'1)1.11-0 I <br /> Deed <br /> Purchase Agreement (� A n <br /> 14. When do you intend to open for business? 4c Syr) 0 }s poss l 6k 1 <br /> 15. What will be the main nature of business? '-fp 9 p (tE r fly-t,rA s.0- <br /> 16. What are the anticipated hours of operation? 9— 12:00 4-M <br /> ®List the principal residence(s)for the past 10 years for all persons required to sign,including spouses. <br /> ��'" r jtf a F.q�d b kti4r .. bAMknvA. Tewxu x, ,,,..rt t .y .. <br /> Y� a aM are.. ....kin 3vrrar6aorx,, , e- Yi�.r {Y..4 ,"^cam` ;1,9- <br /> 3e .P� 3i. `� 4 ._�W3.YCaaNLOJ..>ck'ff n.2L x.1 u^ tSh�B��naan.�x>"e.(iYiM+x ,zdt� ,.. �"' li <br /> YEAR SPOUSE:CITY&STATE YEAR <br /> FROM TO FROM TO <br /> r.. ∎.a..a....Y-....y -■—_ <br /> G"w,d 1 Shot d N -e. OP? 2007 i <br /> 191.+a Iv-e... pod') praim! <br /> If necessary attach a separate sheet. <br /> FORM 100 <br /> REV MAY 2015 <br /> PAGE 7 <br /> 1 <br />