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<br />Bingo Hall License Application (CG300) - Part 2
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<br />6. Have/do any persons listed In items 4, 4a, 5, and 5a: Yes No ~
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<br />a, been oonvlcted of a felony in the last five years? [::J ~
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<br />b. ever been convicted 01 a felony involving fraud or misrepresentation or a crime involving gambling? r--.J 0
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<br />c. owe delinquent taxes in excess of $500 as defined in Minnesota Statutes section 270. 72? [~~
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<br />7, Are any of the individuals listed in items 4, 43, 5, and 5a a licensed distributor, licensed manufacturer ~ [-J
<br />or an affiliate of a distributor or manufacturer of gambling equipment or a wholesale distributor of ).L-J ---
<br />alcoholic beverages?
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<br />I doclare that this application is correct and complete to the best 01 my knowledge and belief. I willlamiliarize myself with the laws of the
<br />state 01 Minnesota nnd rules 01 the Board rogarding gambling and agree, if licensed, to abide by those laws and rulos, including i11T18nd-
<br />menls to them. Changes in the information submitted in lhis application will be submitted to the Board and local government unit within ten
<br />~~y'~~.!.!.~~~hange occurs ___ __ __________._____._._.____________ ______._.____ __________.___.
<br />~. Si ture 01 Ch.~et executive olficer ol~he lenor D.at";. / . Name (please print). . Ti.'I.e
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<br />. Name of person completing this form Title Phone
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<br />1- OU11:5 LJJ C\~sH ____________E.(<,J~''T:!CNT _~~~t[3g 8J1'b.
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<br />_l\.ckno7Jled~ement of Notice by Local Gover.n!n~ Bod~1 '.{:':/::" ::';),}):,{:':'{::C::-:.:':H:){:'{::::::::U-:\(n:t~):::'H:/.}\~:::). .,
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<br />(The city" must sIgn If the bingo half Is located within city limits. The county ""AND townshIp" must sign if the bingo hall is
<br />located within 8 township.)
<br />I have received a copy of this application. This application will be reviewed by the Gambling Control Board and Department of
<br />Public Safety, and may become effective not less than 60 days from the date ot receipt by the city or county, unless the local
<br />government passes a resolution to deny the activity. A copy of that resolution must be received by the Gambling Control
<br />Board within 60 days of the dale lis led below. II the local governing body (city or county) chooses to waive its right to deny
<br />the license within t}le 60day period, tho local governing body must notify the Board in writing 01 the wa,i~___.._________
<br />Q.it{ or Counf)'....- ~_~n-~=--=~~_-~--_===-~==-=-~~~Io_wn~llip... ~=__-=___" __~_m___
<br />to. City or county name /J~ /~ 1 t. Township name
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<br />---.LLLi cJ? fff:::~~t1!___,;,{-_0 _~_____~___ _____ u__.~
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<br />Signat f person receiving application Signature or person receiving 8ppllc8tion
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<br />Tille 1f!3 ale receive "y penD -I--~rlile n Township officiai----~ 'Dale 'eceived----
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<br />e/ J1f JJJ;J!/II!S begins Iron5~8p ;1 () _I u___________ _~~m__
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<br />Nmne of person delivering application to local government Is township? organized unorganized unincorporated
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<br />.!..- Ou / c LU A L_b. i-j ". __~________~~-'----=~~!__ ,. ==1
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<br />Ginao Hall ADolicatJon and reauired attachments: Where to mall the 13oplica1ion and allachlnents
<br />-Form CG300, Bingo H8.11 License Application. Parts 1 and 2 Department 01 Gaming
<br />-Form CG302, Bingo Occasion list Gambling Control Division
<br />-Form CG315, Bingo Hall Personnelln:ormCliion Mail Station 3315
<br />(lor each person listed in items 5, Sa, 6, and 6a on lorm CG:JOO) St. Paul, MN 55146-3315 ~
<br />'Check for license fee 01 $2,500, made payable to
<br />"Commissioner of Revenue"
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