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<br />CG315 Minnesota Lawful Gambling .
<br />(f'",. (101171"( Bingo Hall Personnel Information
<br />BinJ!O Hall Information .... ... ... ....... ....,.::,.:<:,':.::,':::..::.::::::".:,):.',':'.)(:;."""""""""""",...:,:<::::1'1'
<br />1. Name of bingo hall Phono
<br />/ POT '0' Cold '1=}~1)c,v ...L.J.//s (pl:i\ 03/ (3/~____
<br />Address City State Zip code ,.,
<br />;j "7 7 (" CON A./V14- /JKDtrJ)/ IIr 41 /U 63- j/ 2.-
<br />.
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<br />Personnel Information
<br />2. Last name . I I First name
<br />wALSH /..CJUIt5 ~_..J-~3
<br />3. Home address Home Phone
<br />--.l. -,,< - (61..:v '77c:;;,. '7!!2'0-
<br />4. Driver's license number I Name of spouse
<br />Lu "f_O ..; B~ 01.. 7 M.3 /'17 ji,I <;; '1:)_ __ ~N ..0{... .,
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<br />~~___~ra:h O~._~i~ta~ S;;{W Dates of ServiCB j Le~~~~i~::~~i_~~.~~_~~~a
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<br />6. Your position wi~-ti'ngo hall (check one) 0
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<br />Work phone (c;./.;t) <.f8'1f' f(.,) ';,-
<br />. _ C<jI!U.T 1<'--..11 r/?.4,/V'jIlI,v .6u, kJ,'.l-J-
<br />7. Employment record for past 10 years (include periods 01 unemployment or education)
<br />____imployer Addross Type 01 businoss Positio~'l~~~~____--.!?(ltes o~~~_:?!?xmenr.
<br />
<br />~- --rL/I1",:__IL~=--~o~j-p~()::n- -- e._qR._---OU-/AA,4 1210 -As:_~
<br />- ------~_.
<br />.-.----- --"-'"-~ ----
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<br />----. . ~.._---------------~~------ ,-._----- _.._~---------- --------.---...
<br />8. Place of residence for past 10 years
<br />Address _ _ .. City. .. . .. Slale. _ ____ZjJ code ___2'~~~~_~~idence _____.___~_
<br />
<br />-Lit 6M /;), '------YJ-;;~-4,;;-. 66/0<:. l.ycfV- ,PJf"S~rA
<br />--1.6 ~___ _5ir_P~L________ ,--------------~~ ----.
<br />
<br />___no. ..______ .____._~____..__.________.~________" ___________ ______,_____~____,____
<br />
<br />---------- ----~--- ,...---. ----------- ------. ---. ----~-~--
<br />9. Criminal history statement (except petty misdemeanors). II none, write ~none,"
<br />oa~I_-"-Cha,,,,-- ,__~__ ___ Ciryan<J.state___ Dicposifion______,
<br />
<br />
<br />=--~-=~--~-==-- -- ---=~~---- ----~----
<br />
<br />- ----~--
<br />---~-------
<br />10. Name, address, and license or exemption # of any organization you belong to which conducts lawlul gambling.
<br />If none, write "none."
<br />Organization -- -.----- --. ------.-~--- license or Exemption NU:1l0er
<br />
<br />f1 ) QIL/C-, _____~_ ,______
<br />Address City Stale Zip code
<br />
<br />-. --- ---.-.._----- --------- -------~------_.,---------
<br />Organization License or Exempt:or; Number
<br />
<br />Address - ---Ciry--------- Slale Zip code
<br />
<br />-----~----
<br />-~-- -------
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<br />CC<Clre lla\ I IS app!icallon IS correct an comp eta to H,e est 0 my now,edge art )Cole. understand .hat
<br />s _~~~:ial 01 license or revocation of any licenses 9r_~_~~.~d.
<br />
<br />~ Dale
<br />
<br />. n__n n_P/!l T ~__Lf'f'a~
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<br />Attach this form to the Bingo Hall License application CG300
<br />M Depar1ment 01 Gaming - Gambling Control Division, Mail Station 3315, Sl. Paul, MN 55146-3315
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