RES 2004-1479 - Appoint Braden W Daniels manager of Veterans FW Florence 3421 STATE OF NEBRASKA
-'""gE`S T\"rF' RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION
of nn' a
..�• • Hobert B. Rupe
.2', OCT04 2/7 /8q 4♦t Executive Director
H _ft At, 301 Centennial Mall South,5th Floor
t �' _ P.O. Box 95046
ti�1
i t_ i i. Lincoln,Nebraska 68509-5046
7*1 I�
4 \ F a l i p • Phone(402)471-2571
' ,1,\\ gR..., �;�, i'� �'" :7 f is Fax(402)471-2814
TRS USER 800 833-7352(TTY)
Mike Johanns web address:http://www.nol.org/home/NLCC/
Governor
October 25, 2004
City Clerk
Omaha/Douglas Civic Center
1819 Farnam LC-1
Omaha NE 68183
RE: Manager Application Submittal
Dear Sir/Madam:
The enclosed Application for Manager is being submitted by Veterans FW Florence 3421
DBA Veterans FW Florence 3421 located at 9318 N 34th, Omaha, NE 68112 (Douglas County)
which holds a Class C License #5907 the applicant's name is Braden W. Daniels.
Please present this application to your City/County Council and return to us the results of
the action taken. If you have any questions or comments, please give me a call.
Sincerely,
{ Michel - Porter
Licensin ivision
Enclosure
Rhonda R. Flower Bob Logsdon R.L. (Dick)Coyne
Commissioner Chairman Commissioner
An Equal Opportunity/Affirmative Action Employer
Printed with soy ink on recycled paper
e
Application fQ� Corp IVlanagerEr F'p p.
*Must Be� b ,side, t*
Please submit in Triplicate
Return to: Nebraska Liquor Control Commission,PO Box 2 5 2004 CCT 1 2204
Phone: 301
n NE 68509
402 471-2571 CentennialFax 402 4 1-2814 col Web addres t p, /Ayw v lip e/NLCC/, "' :,,f' ",1' i ""1
t..
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Veterans FW Florence 3421 CLASS&LICENSE NUMBER
_ C.;-- R-614) i'MP..V -7
- - —--
Veterans FW Florence 3421
STREET ADDRESS OF LICENSED PREMISE CITY COUNTY ZIP CODE
?•5/g /3 Ofi4a4 a _Pau 7/.0.5 (o&117
On behalf of the corporation,I designate this individual as corporate manager.
Signature of Corporate President/CEO:
*T- 546,196:AN-0)
................................:.............:................:.......................................................
NAME
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MIDDLE,MAIDEN) ••...v.SEX;.:.:;.: SOCIAL, •.,•.,;.
> SECURITYNUMBER
(LAST, DATE OF BIRTH PLACEOF-•BIRTH
HOME STREET ADDRESS CITY COUNTY STATE ZIP CODE
zit/ 1/i/I)'44127; St- (2/44 a44 Z) 9/ N'6 6g'ii
HOME TELEPHONE NUMBER BUSINESS TELEPHONE NUMBER DRIVERS LICENSE NUMBER&iTATE
(Yaz) ("Cl - --/ .. (s y4-7- � 'o1
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FULL NAME(LAST,FIRST,MIDDLE,MAIDEN) SOCIAL SECURITY NUMBER DRIVERS Lt NUMBER
-Th• ' � j ? � / n (kYI1T) & ATE ._ , �,
DATE OF BIRTH: -T - PLACE OF BIRTH f' , .iy /v��� �/
1. READ CAREFULLY. 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 criminal charge. Criminal
charge means any charge alleging a felony or misdemeanor violation of a federal or state law;or 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.
❑Yes sci No
•
2. Have you or your spouse ever made application for any liquor license or manager for any liquor license? IF YES,for what premise
give license number and date.
AYES PINO
FORM 35-4013
REV 2/01
>*.prerbd m recycled paper PAGE 1
3. Have you or your spouse ever made a compromise settlement for violation of such laws?
DYES ANO
4. Do you,as a manager,have all the qualifications required by any person entitled to hold a Nebraska Liquor License?
Nebraska Liquor Control Act(§53-131.01)
AYES ❑NO
5. Have you filed fingerprint cards and PROPER FEES(if check,make out to the NE State Patrol),with this application?
YES ONO
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APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR
FROM TO FROM TO
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03 ,g/I,e��1�/d��1.U,r, Pei/Lft rid e,-0•r,,�,,. /�rr'0j /7/YSG/�GI�Q _: 7/ '�
AI-/iv/ik41 Gd.N 5!v /AQd7/FL ! //7�i_Ze227 207 (Nit?, f9
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
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STATE OF NEBRASKA )
) SS
COUNTY OF )
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. If spouse has NO interest directly or indirectly,an
affidavit of non participation may be attached.
The undersigned understand and acknowledge that any license issued,based on the information submitted in this application,is subject to cancellation ifthe information contained herein
is incomplete and inaccurate.
-01 - Le &t2.7a3
Signature of AA) t ignature of Spouse(if applicable)
Subscribed i pres ce and swop!t�o before me this W . Subscribe resence d sw m to before me this tJ`-�
day of ±�" l) !()1�C day of � 1/
GENERAL NOTARY-State of Nebraska ` GENERAL NOTARY-State of Nebraska
JILL R.MO EY JILL R.MO
�;ice.
otary 'gna &Segt=— a ��"
Notary Signa
FORM 35-4013
REV.2/01
PAGE 2
1
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OCT 2 5 2004
NEBRASK;q LIQUOR
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NEBRASKA LIQUOR CONTROL COMMISSION
AFFIDAVIT OF NON PARTICIPATION C.T 13 2904
i:t::i3 A v UQUC r
The undersigned individual acknowledges that he/she will have no interest,direc'tly or indirectly,m
the operation or profit of the business, as prescribed in Section §53-125(13)of the Liquor Control
Act. Such individual shall not tend bar,make sales,serve patrons,stock shelves,write checks,sign
invoices,represent themselves as owner or in any way participate in the day to day operations in any
capacity. Undersigned will also be waived of filing fingerprint cards, however, has disclosed any
:CT
v'. ation,$) on application. CEnil �ti_�- .iia_k �.�b—) 2
5 2004
Signal of Spouse NE8R4$
CONTROL ogislR
ON
SUB CRIBED in my presence and sworn to before me this Or day of
%.).4i.
. GENERAL NOTARY-State of Nebraska
w, JtLL R.MO
(e_14(kj
MY Comm.R. S
_ ,
Signature� otary Public
The licensee/applicant understands that he/she is responsible for compliance with the conditions set
out above, and that I suc are violated,the Commission may cancel or revoke the license.
t 96444_.<�� (,dark,�-
Signature of Licensee/Applicant Print Name of Licensee/Applicant
SUBSCRIBED in my presence and sworn to before me this Off day of
a_W)eir , 2c0ti .
GENERAL NOTARY-State of Nebraska
JILL R.MQ EYld/
n „.� My Comm.Exp.II rzc 6
.! _
ignature of otary Public
FORM 35-4178
REV 2/01
40 printed on recycled paper •
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