RES 2010-0537 - Appoint Mark E Schiffmann manager of Walgreens #07563 04�xE`STA T�,4q1
;`T.A k EC E j V E I i STATE OF NEBRASKA
104 al,.y Dave NEBRASKA LIQUOR CONTROL COMMISSION
� ,Yw„ Heineman
!ti��:-; r_4 ' Governor FEBn Hobert B. Rupe R!�ll. I 0 FEU v 9 iw1 r, 9: 14.U Executive Director
301 Centennial Mall South,5th Floor
P.O.Box 95046
CITY CLERK Lincoln,Nebraska 68509-5046
n m A N A. NE:BR.CSK Phone(402)471-2571
Fax(402)471-2814
TRS USER 800 833-7352(TTY)
web address:http://www.lcc.ne.gov/
February 5, 2010 •
Omaha City Clerk
1819 Farnam .
Omaha NE 68183
Dear Clerk:
Enclosed is a copy of a manager application for Mark E. Schiffnann in connection with
the pending application for Walgreens Co dba Walgreens#07563, located at 8989 W Dodge
Road, Omaha NE.
Please present this application for manager to your City Council and send us the results
of their action.
Sincerely,
NEBRASKA LIQUOR CONTROL COMMISSION
COu6" 30,•.4)A,22)
Mary Messman
Licensing Division
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encl.
cc: file
Janice M.Wiebusch Bob Logsdon Robert Batt
Commissioner Chairman Commissoner
An Equal Opportunity/Affirmative Action Employer
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Signature of spous 'ng f aiver Printed name of spouse asking for waiver
(Spouse of individual listed below)
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State of 2toroCY_QA i
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date name of person acknowledged
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Signature of individual olved with application • Printed name of applying individual
(Spouse of individual listed above)
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State of 'Ie Y-Os k-°-\ I
County of �('�) Q S - The foregoing instrument was acknowledged before me this
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( ijU/ -
date name of person acknowledged
�. ��nAffix Seal GE ARY— of Neb!& aU!/(, ASHIEY MONTGOMERY
Notary Public gnature - '- My Comm.Exp.Sept.12,2012 •
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
I
FORM35-4178
Revised 1/2008
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MANAGER APPLICATION Office Use -11
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. INSERT FORM 3c
301RASKA 01 CE Nr LIQUOR
oi►Ail,SOUTH COMMISSION FEB 5 2010
PO BOX 95046
PHONE (4 2) 71-25 1 NEBIRASI(A LIQU®R
PxoxB:�aoz)a71-zsn
FAX:(402) w.lcc.14 CONTROL COMMISSION
Websita:www.icc.ne.gEry
Corporate manager,including spouse,are required to adhere to the following requirements
If spouse Sled affidavit of non-participation fingerprints and proof of citizenship not required -
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1) Must be a citizen of the United States
2) Must be a Nebraska resident(Chapter 2—006)
3) Must provide a copy of birth certificate,naturalization paper or US passport i
4) Must submit fingerprints(2 cards per person)
5) Must be 21 years of age or older
6) Applicant may be required to take a training course
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Name of Corporation/LLC: WALGREEN CO.
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Premise License Number:. I PL & __A t�
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(if application leave blank)
Premise Trade Name/DBA: Walgreens#07563
Premise Street Address: I 8989 W Dodge Road
City: Omaha Zip Code: I 68114 1
Premise Phone Number:, A02-393_ 029 L
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State of 'Ie Y-Os k-°-\ I
County of �('�) Q S - The foregoing instrument was acknowledged before me this
Tal\U- A\ILO 10 by kQ( -- SC.-In 1 4 YY\A.n ),
( ijU/ -
date name of person acknowledged
�. ��nAffix Seal GE ARY— of Neb!& aU!/(, ASHIEY MONTGOMERY
Notary Public gnature - '- My Comm.Exp.Sept.12,2012 •
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
I
FORM35-4178
Revised 1/2008
1
TATE YEAR CITY&STATE 1 YEAR
FROM TO FROM TO
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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.
EYES KNO If yes,please explain below or attach a separate page.
............_ ....Y'..--.. . . .. ........... ...._.... _. ............ .......... ....-....... ..... . _..... .._.... .-....._. ._............. .,.... _...
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.
W A t_6•42EEEn1 tat)6-
'4 YES ONO 3q4 Nr:42.TH sADDw zE-E , (Drti p+N??, OE
3. Do you,as a manager,have all the qualifications required to hold a Nebraska Liquor License? Nebraska
Liquor Control Act(§53-131.01)
OYES 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)
OYES (ENO
5. Do you have any experience in selling alcohol in the State of Nebraska?
If so list training and/or experience(when and where) ac:Zoc-Y---2Q,6r
Date: Where:
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_ %,� `e' }- sr. lj...f�..,�t��� f -lW_ i ter 3 �74.,•.. , p.41,'--ii Jw:*."his:.''`� '.rr 4 s,r- " °L' ".P 4:s
SFii Ss° ` y : ^• .q S` �' e6 A 0. "�..,1 `^ .d.t,' $e� } 44 " x+1,,k f. i t 7
:ii m s a � ;�3srE�� i fa �Y _ C�_ a t:tr." +K� � r f:
k< 'k. ,�� eJ'1:. .. z .A.t? ',.;,..,W.,::',,?.,:F "` 1 -. .4 v.�. f. 11?` l {�,3y •..}s__... �-,,,°- ,.. -�.t 'C.`
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.
ignature of Man er Applicant Sign re of `.! } I se
State of Nebraska
County of `J0J6L.)S County of (oL.f S
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
me this<Sam)ariA Z`)I r 2-010 by \-A Soh: lam me this rf 0 rNv� 2-1 t r l o by Debt "h:' 7714
Notary Publi ignature Notary lic signature
Affix Seal Here Affix Seal Hero.......-...,...,
!i OENERAI UOTARY-Mete of Nebraska
OEIERAL ROTARY-State of Nebraska ASNLEY MONTGOMERY
ASHLEY M "°ONTGOMERY •�• ''`"tz , My Comm.Exp.Sept.12,2012
My Comm.Exp.Sept.12,2012
IREPERWISOMOMMIPIMIMarRsramecrvmarzig
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
i Page 4
Form 3c .
r? -!...tv,itik.I, wt, Altsii=.11, ..-'.: "4,400.47 ,.-,ila. •;!..,,,,,
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CITY&STATE YEAR CITY&STATE YEAR
FROM TO .
FROM TO
j 198s, 20100 . ____ __OMAHA) NE egAski4
_ _ _ _ _ ___ _ _
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FROM TO
=
f 17 ' 2010 1,J Auvree-E1J ,b12v er- • MickiBEL- Filb+ILey . Ltoz--s-sl-qoql I
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-.-:.1,-:vrq-:: .t .,--„, 4- Is i ,:,4.V..,t,:et''*'.4' :'...11. ''..t.3..-':-''''';-..f. - ;1#0.-.'lt 3‘.-'gre.tAle: 4:4i;-g-,.'.".. •,L-NAiik,,. ••_,,g;,-•:•.1.k t: '!'s..... 5'.''''.4..:*
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_ . • . i
Form 3c Page 2
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. - ' SPOUSAL AFFIDAVIT OF Office Use
NON PARTICIPATION INSERT I
1 •
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046 e •PHONE:(402)471-2571 t
FAX:(402)471-2814 -
. Website: www.lce.ne.Qov
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LI De,b rk M , S ck; /4-n '
Signature of spous 'ng f aiver Printed name of spouse asking for waiver
(Spouse of individual listed below)
State of N Qi,Or('lk
. County of < (.7 S The foregoing instrument was acknowledged before me this
Toyw a r t 21 I/3\ Q ,_.-b� b Cyril k M , S(Al i !--Pf'Y\ot h Y\
J date name of person acknowledged
a/„..jkii.j.„.
Affix Sev ;-:m :d-�t.,
9' ;0F;+ ;�i.ii0TA.ftY-date of Nebraska
P ., i 0,E.Y MONTGOMERY
ii
Notary Public sigl ure t;�sra - . I).Exp.Sept.12,2012
•
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Signature of individu4,:j
„2,...al olved with application Printed name of applying individual
(Spouse of individual listed above) F
State of ek -Os k-0-1 • :I
i
County of DCJ..)(> a S The foregoing instrument was acknowledged before me this
TaINU(�Y ) •
�\3'0 t 0 by Re(( - suk i •irA I'\ r\
aialAktita
J date name of person acknowledged
�� Affix SealNEW.NOTARY-StateofNebraska
(J�/ gi ASHLEY MONTGOMERY
Notary Publi ature may: >-._•_;:
My Comm.Exp.Sept 12,2012
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format. -
IFORM 35-4178
i Revised 1/2008
1
I
I ,
A,_tifda,1,; ...•‘;' .1.i.E,-;:f :'it: I; 4.-,i, ::,, , • ';:,.:;,,,,,A. -- ' :...,..,',...,..--,..,...i,„,..1...:... .:X.:, ',.,:-.:3:'4...36.i.-:ko..'.i ...•,:,-c.,:.::s.),;,..'-'i.i
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
=
f 17 ' 2010 1,J Auvree-E1J ,b12v er- • MickiBEL- Filb+ILey . Ltoz--s-sl-qoql I
N /A 1 i
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-.-:.1,-:vrq-:: .t .,--„, 4- Is i ,:,4.V..,t,:et''*'.4' :'...11. ''..t.3..-':-''''';-..f. - ;1#0.-.'lt 3‘.-'gre.tAle: 4:4i;-g-,.'.".. •,L-NAiik,,. ••_,,g;,-•:•.1.k t: '!'s..... 5'.''''.4..:*
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_ . • . i
Form 3c Page 2
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0MAHA, �F
City of Omafia, Webraskg 714bpsAll1.4101MiffrOla
1I�'
1819 Farnam Suite LC 1 •
Omaha, Nebraska 681 83-01 1 2 �o® �'; ^'
Buster Brown (402) 444-5550 o
City Clerk FAX (402) 444-5263 'Q4TFp FEBRv!►�
April 20, 2010
•
Walgreen Co. Application to appoint Mark E. Schiffmann
dba"Walgreens #07563" manager of your present Package Liquor
8989 West Dodge Road License
Omaha, NE 68114
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 May 4, 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
sia aa 3_ �;sl x4
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LI De,b rk M , S ck; /4-n '
Signature of spous 'ng f aiver Printed name of spouse asking for waiver
(Spouse of individual listed below)
State of N Qi,Or('lk
. County of < (.7 S The foregoing instrument was acknowledged before me this
Toyw a r t 21 I/3\ Q ,_.-b� b Cyril k M , S(Al i !--Pf'Y\ot h Y\
J date name of person acknowledged
a/„..jkii.j.„.
Affix Sev ;-:m :d-�t.,
9' ;0F;+ ;�i.ii0TA.ftY-date of Nebraska
P ., i 0,E.Y MONTGOMERY
ii
Notary Public sigl ure t;�sra - . I).Exp.Sept.12,2012
•
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ht vik
Ll` tei Fl Q 3 :^�a•.. o}N k 4hl E'y, g � , " < :.> u�3 ? �
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Signature of individu4,:j
„2,...al olved with application Printed name of applying individual
(Spouse of individual listed above) F
State of ek -Os k-0-1 • :I
i
County of DCJ..)(> a S The foregoing instrument was acknowledged before me this
TaINU(�Y ) •
�\3'0 t 0 by Re(( - suk i •irA I'\ r\
aialAktita
J date name of person acknowledged
�� Affix SealNEW.NOTARY-StateofNebraska
(J�/ gi ASHLEY MONTGOMERY
Notary Publi ature may: >-._•_;:
My Comm.Exp.Sept 12,2012
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format. -
IFORM 35-4178
i Revised 1/2008
1
I
I ,
A,_tifda,1,; ...•‘;' .1.i.E,-;:f :'it: I; 4.-,i, ::,, , • ';:,.:;,,,,,A. -- ' :...,..,',...,..--,..,...i,„,..1...:... .:X.:, ',.,:-.:3:'4...36.i.-:ko..'.i ...•,:,-c.,:.::s.),;,..'-'i.i
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
=
f 17 ' 2010 1,J Auvree-E1J ,b12v er- • MickiBEL- Filb+ILey . Ltoz--s-sl-qoql I
N /A 1 i
i.-,„..•:,-a7m,„,•; 1 ..74 „_..,,, :-qr.-- 't.--.: 'lir...7i7,7 .; y 7 7 qr,,::.;,,-,,,..vz.;...,;k" .-T,..fl,ilet::,#-:. ,, 41';:yr-ii 16r: ,-,- ,-,;:-;. _,••7-,. -:!-,1:-,.7 ,T,.-.,-,,,,g-,----42
-.-:.1,-:vrq-:: .t .,--„, 4- Is i ,:,4.V..,t,:et''*'.4' :'...11. ''..t.3..-':-''''';-..f. - ;1#0.-.'lt 3‘.-'gre.tAle: 4:4i;-g-,.'.".. •,L-NAiik,,. ••_,,g;,-•:•.1.k t: '!'s..... 5'.''''.4..:*
n
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.-.,i_......-_,_!,..,,,--.-....,.'-,c,_';, .. ._. --•- .!:'.:g..--.3,4'.." -c-4?-:!...' _,,,:-:',..1 ...:: L'i,-.4.:-.42,..,,.'.--,..,..,i,-.-- ..4-_454-01-47....:•-•:,,-4-4,Awt.-2-t--..r-g". ',.:_!----,...._ "2....:...riz....",...-44... .1..-...
_ . • . i
Form 3c Page 2
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,. 1
i i
otA
City ofOmaha, J\febraskg 111
'ap—k,
1819 Farnam Suite LC 1 2 vi ilr
Omaha, Nebraska 68183-0112 � '� �'
Buster Brown (402) 444-5550 '�
City Clerk FAX (402) 444-5263 o4)47.FD FEBRr4�
April 20, 2010
Mark E. Schiffmann Application to be appointed manager of the present
725 North 154th Avenue Package Liquor Licenses for Walgreens Co. - see
Omaha, NE 68154-3755 attached list of locations
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 May 4, 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
L tF ta R , x• � ' �`
B' � m = h�7c& rt '�.. . !.'B ,� Yw�t. , {� �u.m� _ •5 .e,Ta� ,ew.<..... s_..WmC,-3t/a r.5r M�r-.�„�..s$ JY' 7��.!57 I
LI De,b rk M , S ck; /4-n '
Signature of spous 'ng f aiver Printed name of spouse asking for waiver
(Spouse of individual listed below)
State of N Qi,Or('lk
. County of < (.7 S The foregoing instrument was acknowledged before me this
Toyw a r t 21 I/3\ Q ,_.-b� b Cyril k M , S(Al i !--Pf'Y\ot h Y\
J date name of person acknowledged
a/„..jkii.j.„.
Affix Sev ;-:m :d-�t.,
9' ;0F;+ ;�i.ii0TA.ftY-date of Nebraska
P ., i 0,E.Y MONTGOMERY
ii
Notary Public sigl ure t;�sra - . I).Exp.Sept.12,2012
•
14, go
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ht vik
Ll` tei Fl Q 3 :^�a•.. o}N k 4hl E'y, g � , " < :.> u�3 ? �
_, r k .I,, ct �,
Signature of individu4,:j
„2,...al olved with application Printed name of applying individual
(Spouse of individual listed above) F
State of ek -Os k-0-1 • :I
i
County of DCJ..)(> a S The foregoing instrument was acknowledged before me this
TaINU(�Y ) •
�\3'0 t 0 by Re(( - suk i •irA I'\ r\
aialAktita
J date name of person acknowledged
�� Affix SealNEW.NOTARY-StateofNebraska
(J�/ gi ASHLEY MONTGOMERY
Notary Publi ature may: >-._•_;:
My Comm.Exp.Sept 12,2012
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format. -
IFORM 35-4178
i Revised 1/2008
1
I
I ,
A,_tifda,1,; ...•‘;' .1.i.E,-;:f :'it: I; 4.-,i, ::,, , • ';:,.:;,,,,,A. -- ' :...,..,',...,..--,..,...i,„,..1...:... .:X.:, ',.,:-.:3:'4...36.i.-:ko..'.i ...•,:,-c.,:.::s.),;,..'-'i.i
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
=
f 17 ' 2010 1,J Auvree-E1J ,b12v er- • MickiBEL- Filb+ILey . Ltoz--s-sl-qoql I
N /A 1 i
i.-,„..•:,-a7m,„,•; 1 ..74 „_..,,, :-qr.-- 't.--.: 'lir...7i7,7 .; y 7 7 qr,,::.;,,-,,,..vz.;...,;k" .-T,..fl,ilet::,#-:. ,, 41';:yr-ii 16r: ,-,- ,-,;:-;. _,••7-,. -:!-,1:-,.7 ,T,.-.,-,,,,g-,----42
-.-:.1,-:vrq-:: .t .,--„, 4- Is i ,:,4.V..,t,:et''*'.4' :'...11. ''..t.3..-':-''''';-..f. - ;1#0.-.'lt 3‘.-'gre.tAle: 4:4i;-g-,.'.".. •,L-NAiik,,. ••_,,g;,-•:•.1.k t: '!'s..... 5'.''''.4..:*
n
v.-4/,. '.. ...'--..-=:, A . P,..- -" -...*.:` ,1 .44=61.A,..-,,,, 1 .r.:-AvhAt:-,,.....,,,,_A411.24'.41-, ,...-lj-4''',e. .- . ,eva = .-,r -,` ...- = ,„_.•,,,,,,j,71-1-4,1-fai, ,%--",
.-.,i_......-_,_!,..,,,--.-....,.'-,c,_';, .. ._. --•- .!:'.:g..--.3,4'.." -c-4?-:!...' _,,,:-:',..1 ...:: L'i,-.4.:-.42,..,,.'.--,..,..,i,-.-- ..4-_454-01-47....:•-•:,,-4-4,Awt.-2-t--..r-g". ',.:_!----,...._ "2....:...riz....",...-44... .1..-...
_ . • . i
Form 3c Page 2
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WALGREENS CO.
MARK E SCHIFFMANN MANAGER OF THE FOLLOWING LOCATIONS:
WALGREEN CO 9001 WEST CENTER ROAD
DBA WALGREENS #04443
WALGREEN CO 5038 CENTER STREET
DBA WALGREENS #04974
WALGREEN CO 7151 CASS STREET
DBA WALGREENS #05143
WALGREEN CO 2323 "L" STREET
DBA WALGREENS #05190
WALGREEN CO 8989 WEST DODGE ROAD
DBA WALGREENS #07563
WALGREEN CO 225 N SADDLE CREEK ROAD
DBA WALGREENS #07693
DBA WALGREENS #07693
O LA
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