RES 2010-0723 - Appoint Ashley J Pivonka manager of DC Centre �OF-;E T.\.Tq y.„
fv ��i4,
rF _ STATE OF NEBRASKA
w � Dave Heineman Q a NEBRASKA LIQUOR CONTROL COMMISSION
y
V ' Governor Hobert B. Rupe
14 ,if Executive Director
t�t\Z.z 'na6'„- 301 Centennial Mall South,5th Floor
P.O.Box 95046
Lincoln,Nebraska 68509-5046
Phone(402)471-2571
May 27, 2010 Fax(402)471-2814
TRS USER 800 833-7352(TTY)
web address:http://www.lcc.ne.gov/
OMAHA CITY CLERK
1819 FARNAM STREET LC-1
OMAHA NE 68183
RE: Dance I, Inc
LICENSE #I - 62711
Dear Clerk:
Enclosed is a copy of a manager application for Ashley 1 Pivonka in connection with DC Centre,
located at 11830 Stonegate Circle in Omaha.
Please present this application for manager to your City/Village Council or County Commissioners and
send us the results of their action.
Sincerely,
Lyn ,umake
Lice ' ision ,
NEBRASKA LIQUOR CONTROL COMMISSION
encl.
cc: file
•
Janice M.Wiebusch Bob Logsdon Robert Batt
Commissioner Chairman Comm issoner
An Equal Opportunity/Affirmative Action Employer
Printed with soy ink on recycled paper
1
e
Nebraska Liquor Control Commission.
Sincerely yours,
Buster Brown
City Clerk
BJB:clj
contained herein is incomplete, inaccurate,or fraudulent. ( "E \JL:i
n,
MAY 12 Z010
. 1j 1l-o-)-- -- -.. NEBRASKA LiQu OE,
Signature of Manager Applicant Signature of Spouse
State of Nebraska
County of iL`e--t County of
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
me this 1— j , / iD by me this by
BLVKA3 Ni)...A.GI.tN
0 ° I Q . V
Notary Pil lic signature Notary Public signature
Affix Seal Here Affix Seal Here
GENERAL NOTARY-State of Nebraska
CAROLYN A CURTIS
My Comm.Exp.Seol.10,2010
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the altemate format.
Revised 5/2007
5/�
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YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPEYONE NUMBER
FROM TO
,2-0 to PRECENT .f Avg l - -ale cit3# 11 5 r• (2 .2
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1000010801
egoing constitutes the entire agreement between the parties and may be modified only ,
by a writing signed by both parties. The following Exhibits,if any,have been made a part of this lease before the
parties'execution hereof:
1I
•
Signed this /7 day of ,200
. By: 472-1"lit, Lessor By: see
tcil.Aep �- a�tm4..$4 .Sher } L.eorarxi
ROSa-smar Att.mmteaAe. a e_ 910 /
•
.Lessor's Remedies an Default. If Lessee defaults in the payment of rent,or any additional rent,or defaults in
the performance of any of the other covenants or conditions hereof,Lessor may give Lessee notice of such default
and if Lessee does not cure any such default within days,after the giving of such notice(or if such other
default is of such nature that it cannot be completely cured within such period,if Lessee does not commence such
curing within such days and thereafter proceed with reasonable diligence and in good faith to cure such
default),then Lessor may terminate this lease on not less than days'notice to Lessee. On
the date specified in such notice the term of this lease shall terminate,and Lessee shall then quit and surrender the
_.......premises to Lessor,without extinguishing Lessee's liability if this lease shall have been so terminated by Lessor,
Lessor may at any time thereafter resume possession of the preiiiies 6y any lawdul means iTurremove Lesttee or er
occupants and their effects,No failure to enforce any term shall be deemed a waiver.
• 15.Security Deposit. Lessee shall deposit with Lessor on the signing of this lease the sum of p4
Dollars(S ) as
security for the performance of Lessee's obligations under this lease,including without limitation the surrender of
possession of the premises to Lessor as herein provided. If Lessor applies any part of the deposit to cure any default
.• of Lessee,Lessee shall on demand deposit with Lessor the amount so applied so that Lessor shall have the full deposit
on hand at all times during the term of this lease.
Pare
•
•
1
MANAGER APPLICATION Office Ur? o‘
INSERT-FORM 3c tUEIVED
NEBRASKA LIQUOR CONTROL COMMISSION /� ��
301 CENTENNIAL MALL SOUTH -� '
PO BOX 95046
LINCOLN,NE 68509-5046
NEBRAMMQVYA L1�C U/Us°0
PHONE:(402)471-2571 CONTROL_COMM
ISSIor
FAX:(402)471-2814
Website:www.lcc.ne.gov
Corporate manager,including spouse,are required to adhere to the following requirements
iffsspouse filed affidavit of non-participation fingerprints and proof of citizenship not required
�!J) ust be a citizen of the United States
Must be a Nebraska resident(Chapter 2—006)
) Must provide a copy of birth certificate,naturalization paper or US passport
i/15 Must submit fingerprints(2 cards per person)
Must be 21 years of age or older
6) Applicant may be required to take a training course
•
e-GName of Corporation/LLC: 6,6 I nO .
c
•
Premise License Number: T— Cp - ( 1
(if new application leave blank)
Premise Trade Name/DBA: .1)0 6C1\-kire/
•
Premise Street Address: 1 O'O `�-4-V I'1 o' a c i-e C11 r
Li
City:Or
V
'r1,ka Zip Code: 1g j(p
Premise Phone Number: Q-Lo0 3"l 3- / "1"
,dia.,,,,...t .(e .k.:4440 )a,A6
CORPORATE OFFICER SIGNATURE
Faxed si_ atures are acce stable)
1111111
1000010807
Form 3c ���
. 1j 1l-o-)-- -- -.. NEBRASKA LiQu OE,
Signature of Manager Applicant Signature of Spouse
State of Nebraska
County of iL`e--t County of
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
me this 1— j , / iD by me this by
BLVKA3 Ni)...A.GI.tN
0 ° I Q . V
Notary Pil lic signature Notary Public signature
Affix Seal Here Affix Seal Here
GENERAL NOTARY-State of Nebraska
CAROLYN A CURTIS
My Comm.Exp.Seol.10,2010
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the altemate format.
Revised 5/2007
5/�
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YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPEYONE NUMBER
FROM TO
,2-0 to PRECENT .f Avg l - -ale cit3# 11 5 r• (2 .2
512Ab(0 Z/ZD 10 Tnier oin I•n IV(J ". id ba; tc 51,6— 63 b - y6 o0_
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•.
1000010801
egoing constitutes the entire agreement between the parties and may be modified only ,
by a writing signed by both parties. The following Exhibits,if any,have been made a part of this lease before the
parties'execution hereof:
1I
•
Signed this /7 day of ,200
. By: 472-1"lit, Lessor By: see
tcil.Aep �- a�tm4..$4 .Sher } L.eorarxi
ROSa-smar Att.mmteaAe. a e_ 910 /
•
.Lessor's Remedies an Default. If Lessee defaults in the payment of rent,or any additional rent,or defaults in
the performance of any of the other covenants or conditions hereof,Lessor may give Lessee notice of such default
and if Lessee does not cure any such default within days,after the giving of such notice(or if such other
default is of such nature that it cannot be completely cured within such period,if Lessee does not commence such
curing within such days and thereafter proceed with reasonable diligence and in good faith to cure such
default),then Lessor may terminate this lease on not less than days'notice to Lessee. On
the date specified in such notice the term of this lease shall terminate,and Lessee shall then quit and surrender the
_.......premises to Lessor,without extinguishing Lessee's liability if this lease shall have been so terminated by Lessor,
Lessor may at any time thereafter resume possession of the preiiiies 6y any lawdul means iTurremove Lesttee or er
occupants and their effects,No failure to enforce any term shall be deemed a waiver.
• 15.Security Deposit. Lessee shall deposit with Lessor on the signing of this lease the sum of p4
Dollars(S ) as
security for the performance of Lessee's obligations under this lease,including without limitation the surrender of
possession of the premises to Lessor as herein provided. If Lessor applies any part of the deposit to cure any default
.• of Lessee,Lessee shall on demand deposit with Lessor the amount so applied so that Lessor shall have the full deposit
on hand at all times during the term of this lease.
Pare
•
•
Gender: n MALE N. FEMALE
Last Name: vca...A, First Name: MI:
Home Address (include PO Box if applicable): Qci Oa AAc&
City: Ofylea. State: VP Zip Code: 1.51 1.Q4
Home Phone Number: 6.1 7 717-1.1)3(11 Business Phone Number:
Social Security Number: _ Drivers License Number& State: '►.�
Date Of Birth _ Place Of Birth: (> * ,
❑ YES DINO
Spouses Last Name: First Name: MI:
Social Security Number: Drivers License Number& State:
Date Of Birth: Place Of Birth:
CITY&STATE YEAR . CITY&STATE YEAR
FROM . TO FROM TO
YEAR NAME OF EMPLOYER . NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
INMEMIL.M11-WIAMIIIIIMPRIPMIngt
•
Form 3c Page 2
•
1. READ PARAGRAPH CAREFULLY AND ANSWER COMPLETELY AND ACCURATELY.
Has anyone who is a party to this application, or their spouse, EVER been convicted of or plead guilty
to any charge. Charge means any charge alleging a felony, misdemeanor, violation of a federal or state
law; a violation of a local law, ordinance or resolution. List the nature of the charge,where the charge
occurred and the year and month of the conviction or plea. Also list any charges pending at the time of
this application. If more than one party,please list charges by each individual's name.
KYES ONO If yes,please explain below or attach a separate page.
Waf kC \tx aA2A % - ��h'►� A $oQ stan 'k'n
v \ cC Qovn
•
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other
state? IF YES,list the name of the premise.
OYES tNO
3. Do you, as a manager,have all the qualifications required to hold a Nebraska Liquor License? Nebraska
Liquor Control Act (§53-131.01)
AYES ONO
4. Have you filed the required fingerprint cards and PROPER FEES with this application? (The check or money
order must be made out to the Nebraska State Patrol for$38.00 per person)
YES ONO ' '' *.219
5. Do you have any experience in selling alcohol in the State of Nebraska?
If so list training and/or experience (when and where)
Date: Where: t Co
-TYAlYl1 ri)
•
Form 3c -- ----- - -- --- Page 3
-- -.. NEBRASKA LiQu OE,
Signature of Manager Applicant Signature of Spouse
State of Nebraska
County of iL`e--t County of
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
me this 1— j , / iD by me this by
BLVKA3 Ni)...A.GI.tN
0 ° I Q . V
Notary Pil lic signature Notary Public signature
Affix Seal Here Affix Seal Here
GENERAL NOTARY-State of Nebraska
CAROLYN A CURTIS
My Comm.Exp.Seol.10,2010
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the altemate format.
Revised 5/2007
5/�
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YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPEYONE NUMBER
FROM TO
,2-0 to PRECENT .f Avg l - -ale cit3# 11 5 r• (2 .2
512Ab(0 Z/ZD 10 Tnier oin I•n IV(J ". id ba; tc 51,6— 63 b - y6 o0_
, pp .
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•.
1000010801
egoing constitutes the entire agreement between the parties and may be modified only ,
by a writing signed by both parties. The following Exhibits,if any,have been made a part of this lease before the
parties'execution hereof:
1I
•
Signed this /7 day of ,200
. By: 472-1"lit, Lessor By: see
tcil.Aep �- a�tm4..$4 .Sher } L.eorarxi
ROSa-smar Att.mmteaAe. a e_ 910 /
•
.Lessor's Remedies an Default. If Lessee defaults in the payment of rent,or any additional rent,or defaults in
the performance of any of the other covenants or conditions hereof,Lessor may give Lessee notice of such default
and if Lessee does not cure any such default within days,after the giving of such notice(or if such other
default is of such nature that it cannot be completely cured within such period,if Lessee does not commence such
curing within such days and thereafter proceed with reasonable diligence and in good faith to cure such
default),then Lessor may terminate this lease on not less than days'notice to Lessee. On
the date specified in such notice the term of this lease shall terminate,and Lessee shall then quit and surrender the
_.......premises to Lessor,without extinguishing Lessee's liability if this lease shall have been so terminated by Lessor,
Lessor may at any time thereafter resume possession of the preiiiies 6y any lawdul means iTurremove Lesttee or er
occupants and their effects,No failure to enforce any term shall be deemed a waiver.
• 15.Security Deposit. Lessee shall deposit with Lessor on the signing of this lease the sum of p4
Dollars(S ) as
security for the performance of Lessee's obligations under this lease,including without limitation the surrender of
possession of the premises to Lessor as herein provided. If Lessor applies any part of the deposit to cure any default
.• of Lessee,Lessee shall on demand deposit with Lessor the amount so applied so that Lessor shall have the full deposit
on hand at all times during the term of this lease.
Pare
•
•
The above individual(s),being first duly sworn upon oath,deposes and states that the undersigned is the applicant and/or spouse
of applicant who makes the above and foregoing application that said application has been read and that the contents thereof and
all statements contained therein are true. If any false statement is made in any part of this application,the applicant(s) shall be
deemed guilty of perjury and subject to penalties.provided by law. (Sec §53-131.01)Nebraska Liquor Control Act.
The undersigned applicant hereby consents to an investigation of his/her background including all records of every kind and
description including police records, tax records (State and Federal), and bank or lending institution records, and said applicant
and spouse waive any rights or causes of action that said applicant or spouse may have against the Nebraska Liquor Control
Commission and any other individual disclosing or releasing said information to the Nebraska Liquor Control Commission.
The undersigned understand and acknowledge that any license issued, based on the information submitted in this application, is
subject to cancellation if the information contained herein is incomplete, inaccurate,or fraudulent.
Sig re of Manager Applicant Signature of Spouse
State of Nebraska
County of rc,� Cc.� County of
C
The foregoing instrume.t was acknowledged before The foregoing instrument was acknowledged before
me this c �&ck• _ I e ',Ro'oby me this by
,4sNLy ' ) voNKA
„")_ (
Not ubli signature Notary Public signature
Affi>C__i -"GENERAL
• Affix Seal Here
GEIERALNOTARY-Stateof Nebnab
PEGGY J.CASE
My Comm Exp.Feb.8,2013
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
Revised 9/2008
Form 3c Page 4
Notary Public signature
Affix Seal Here Affix Seal Here
GENERAL NOTARY-State of Nebraska
CAROLYN A CURTIS
My Comm.Exp.Seol.10,2010
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the altemate format.
Revised 5/2007
5/�
VJ t GEC rr�4, . 1 Z/z•ooi 2'Zo t o C A-ME RoN F /11,O 3�2.000 /2d o l
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�,",, c�5Lt_C c N . 5/zoob t1 zooq
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPEYONE NUMBER
FROM TO
,2-0 to PRECENT .f Avg l - -ale cit3# 11 5 r• (2 .2
512Ab(0 Z/ZD 10 Tnier oin I•n IV(J ". id ba; tc 51,6— 63 b - y6 o0_
, pp .
'FT_-•� ,raj�'•wtisw,.�.ti;. l...Y .a .y ra Ok .tJ�;i i �!' r r+l.,
,
s
. zed.i tutes0•: t le>
1111111111111111111IN
•.
1000010801
egoing constitutes the entire agreement between the parties and may be modified only ,
by a writing signed by both parties. The following Exhibits,if any,have been made a part of this lease before the
parties'execution hereof:
1I
•
Signed this /7 day of ,200
. By: 472-1"lit, Lessor By: see
tcil.Aep �- a�tm4..$4 .Sher } L.eorarxi
ROSa-smar Att.mmteaAe. a e_ 910 /
•
.Lessor's Remedies an Default. If Lessee defaults in the payment of rent,or any additional rent,or defaults in
the performance of any of the other covenants or conditions hereof,Lessor may give Lessee notice of such default
and if Lessee does not cure any such default within days,after the giving of such notice(or if such other
default is of such nature that it cannot be completely cured within such period,if Lessee does not commence such
curing within such days and thereafter proceed with reasonable diligence and in good faith to cure such
default),then Lessor may terminate this lease on not less than days'notice to Lessee. On
the date specified in such notice the term of this lease shall terminate,and Lessee shall then quit and surrender the
_.......premises to Lessor,without extinguishing Lessee's liability if this lease shall have been so terminated by Lessor,
Lessor may at any time thereafter resume possession of the preiiiies 6y any lawdul means iTurremove Lesttee or er
occupants and their effects,No failure to enforce any term shall be deemed a waiver.
• 15.Security Deposit. Lessee shall deposit with Lessor on the signing of this lease the sum of p4
Dollars(S ) as
security for the performance of Lessee's obligations under this lease,including without limitation the surrender of
possession of the premises to Lessor as herein provided. If Lessor applies any part of the deposit to cure any default
.• of Lessee,Lessee shall on demand deposit with Lessor the amount so applied so that Lessor shall have the full deposit
on hand at all times during the term of this lease.
Pare
•
•
�MAHA, NF
city of Omaha, fAfebrasikci .40111kt
Mrifiri%
1819 Farnam — Suite LC 1 f`� -�l, _
C�® -sr
Omaha, Nebraska 68183-0112 0 •:� �,� . ;:;.
Buster Brown (402) 444-5550 �A
City Clerk FAX (402) 444-5263 O�4TBp FEPolk‘ 4
June 8, 2010
Dance I, Inc. Application to appoint Ashley J. Pivonka
dba"DC Centre" manager of your present Class "I" Liquor •
11830 Stonegate Circle License
Omaha,NE 68164
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your
application to appoint a manager to the liquor license has been set for June 22, 2010
The City Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4),
Omaha/Douglas Civic Center, 1819 Farnam Street, Omaha, Nebraska. City Council
Liquor Rule No. 6 states, "Each applicant for any type of license shall be personally
present in the Council Chambers, in order that the Council may make inquiries, on the
date of public hearing of the application for said license". Failure to be present at this
Council Meeting is grounds to recommend denial of your application to the Nebraska
Liquor Control Commission.
Sincerely yours,
444-6°''4/`4:244
Buster Brown
City Clerk
BJB:clj
_ I e ',Ro'oby me this by
,4sNLy ' ) voNKA
„")_ (
Not ubli signature Notary Public signature
Affi>C__i -"GENERAL
• Affix Seal Here
GEIERALNOTARY-Stateof Nebnab
PEGGY J.CASE
My Comm Exp.Feb.8,2013
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
Revised 9/2008
Form 3c Page 4
Notary Public signature
Affix Seal Here Affix Seal Here
GENERAL NOTARY-State of Nebraska
CAROLYN A CURTIS
My Comm.Exp.Seol.10,2010
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the altemate format.
Revised 5/2007
5/�
VJ t GEC rr�4, . 1 Z/z•ooi 2'Zo t o C A-ME RoN F /11,O 3�2.000 /2d o l
P tRDEp / NG t/zoog 'zlzook,
�,",, c�5Lt_C c N . 5/zoob t1 zooq
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPEYONE NUMBER
FROM TO
,2-0 to PRECENT .f Avg l - -ale cit3# 11 5 r• (2 .2
512Ab(0 Z/ZD 10 Tnier oin I•n IV(J ". id ba; tc 51,6— 63 b - y6 o0_
, pp .
'FT_-•� ,raj�'•wtisw,.�.ti;. l...Y .a .y ra Ok .tJ�;i i �!' r r+l.,
,
s
. zed.i tutes0•: t le>
1111111111111111111IN
•.
1000010801
egoing constitutes the entire agreement between the parties and may be modified only ,
by a writing signed by both parties. The following Exhibits,if any,have been made a part of this lease before the
parties'execution hereof:
1I
•
Signed this /7 day of ,200
. By: 472-1"lit, Lessor By: see
tcil.Aep �- a�tm4..$4 .Sher } L.eorarxi
ROSa-smar Att.mmteaAe. a e_ 910 /
•
.Lessor's Remedies an Default. If Lessee defaults in the payment of rent,or any additional rent,or defaults in
the performance of any of the other covenants or conditions hereof,Lessor may give Lessee notice of such default
and if Lessee does not cure any such default within days,after the giving of such notice(or if such other
default is of such nature that it cannot be completely cured within such period,if Lessee does not commence such
curing within such days and thereafter proceed with reasonable diligence and in good faith to cure such
default),then Lessor may terminate this lease on not less than days'notice to Lessee. On
the date specified in such notice the term of this lease shall terminate,and Lessee shall then quit and surrender the
_.......premises to Lessor,without extinguishing Lessee's liability if this lease shall have been so terminated by Lessor,
Lessor may at any time thereafter resume possession of the preiiiies 6y any lawdul means iTurremove Lesttee or er
occupants and their effects,No failure to enforce any term shall be deemed a waiver.
• 15.Security Deposit. Lessee shall deposit with Lessor on the signing of this lease the sum of p4
Dollars(S ) as
security for the performance of Lessee's obligations under this lease,including without limitation the surrender of
possession of the premises to Lessor as herein provided. If Lessor applies any part of the deposit to cure any default
.• of Lessee,Lessee shall on demand deposit with Lessor the amount so applied so that Lessor shall have the full deposit
on hand at all times during the term of this lease.
Pare
•
•
- •City ofOmaha zebras a `� 'tg irs
mortar (p
1819 Farnam— Suite LC 1 �® o� . it
Omaha, Nebraska 68183-0112
Buster Brown (402) 444-5550 A �-
City Clerk FAX (402) 444-5263 oR�TEp FEBRvt►4-
June 8, 2010
Ashley J. Pivonka Application to be appointed manager of the present
12909 Nebraska Avenue Class "I" Liquor License for Dance I, Inc., dba "DC
Omaha,NE 68164 Centre", 11830 Stonegate Circle
Dear Liquor License Manager Applicant:
This letter is notification that a hearing before the Omaha City Council on your
application to be appointed manager of the liquor license has been set for June 22,
2010 . The City Council Meeting begins at 2:00 P.M. in the Legislative Chamber,
(LC-4), Omaha/Douglas Civic Center, 1819 Farnam Street, Omaha, Nebraska. City
Council Liquor Rule No. 6 states, "Each applicant for any type of license shall be
personally present in the Council Chambers, in order that the Council may make
inquiries, on the date of public hearing of the application for said license". Failure to be
present at this Council Meeting is grounds to recommend denial of your application to the
Nebraska Liquor Control Commission.
Sincerely yours, •
Buster Brown
City Clerk
BJB:clj
Brown
City Clerk
BJB:clj
_ I e ',Ro'oby me this by
,4sNLy ' ) voNKA
„")_ (
Not ubli signature Notary Public signature
Affi>C__i -"GENERAL
• Affix Seal Here
GEIERALNOTARY-Stateof Nebnab
PEGGY J.CASE
My Comm Exp.Feb.8,2013
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
Revised 9/2008
Form 3c Page 4
Notary Public signature
Affix Seal Here Affix Seal Here
GENERAL NOTARY-State of Nebraska
CAROLYN A CURTIS
My Comm.Exp.Seol.10,2010
In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the altemate format.
Revised 5/2007
5/�
VJ t GEC rr�4, . 1 Z/z•ooi 2'Zo t o C A-ME RoN F /11,O 3�2.000 /2d o l
P tRDEp / NG t/zoog 'zlzook,
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YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPEYONE NUMBER
FROM TO
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egoing constitutes the entire agreement between the parties and may be modified only ,
by a writing signed by both parties. The following Exhibits,if any,have been made a part of this lease before the
parties'execution hereof:
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Signed this /7 day of ,200
. By: 472-1"lit, Lessor By: see
tcil.Aep �- a�tm4..$4 .Sher } L.eorarxi
ROSa-smar Att.mmteaAe. a e_ 910 /
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.Lessor's Remedies an Default. If Lessee defaults in the payment of rent,or any additional rent,or defaults in
the performance of any of the other covenants or conditions hereof,Lessor may give Lessee notice of such default
and if Lessee does not cure any such default within days,after the giving of such notice(or if such other
default is of such nature that it cannot be completely cured within such period,if Lessee does not commence such
curing within such days and thereafter proceed with reasonable diligence and in good faith to cure such
default),then Lessor may terminate this lease on not less than days'notice to Lessee. On
the date specified in such notice the term of this lease shall terminate,and Lessee shall then quit and surrender the
_.......premises to Lessor,without extinguishing Lessee's liability if this lease shall have been so terminated by Lessor,
Lessor may at any time thereafter resume possession of the preiiiies 6y any lawdul means iTurremove Lesttee or er
occupants and their effects,No failure to enforce any term shall be deemed a waiver.
• 15.Security Deposit. Lessee shall deposit with Lessor on the signing of this lease the sum of p4
Dollars(S ) as
security for the performance of Lessee's obligations under this lease,including without limitation the surrender of
possession of the premises to Lessor as herein provided. If Lessor applies any part of the deposit to cure any default
.• of Lessee,Lessee shall on demand deposit with Lessor the amount so applied so that Lessor shall have the full deposit
on hand at all times during the term of this lease.
Pare
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First Name: MI:
Social Security Number: Drivers License Number& State:
Date Of Birth: Place Of Birth:
CITY&STATE YEAR . CITY&STATE YEAR
FROM . TO FROM TO
YEAR NAME OF EMPLOYER . NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
INMEMIL.M11-WIAMIIIIIMPRIPMIngt
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Form 3c Page 2