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<br /> FOR OFFICE USE ONLY <br /> Fee <br /> Oate_ <br /> LG300 Chk Initial I <br /> (Aev.101'3Cr190) Minnesota Lawful Gambling License # <br /> . Bingo Hall License Application - Part 1 <br /> (See instructions for completion ofthls application) <br /> Is this application for a new license, or a renewal? 0New 0 Renewal <br /> ~f.:r1!0!!~~~itftlgl\tl&gl~liiil~\1}iljMl&%f~ilfujlJM:~lft!litlifi!!jtt}lij;!iil!iW~$11jl~1!};i!J!1![111\11~1!j1\~]~ri;11j;jliljll1;jl:l!ljli;ill11!11il;'j;jlijll <br /> 1. County (where hall is located) <br /> 2. Mailing address of bingo hall City ~l/<; <br /> 3 :7)7 b /'~#/P/~v A-dtP// M4/" 1;"'<;-// 'J <br /> 3. Is the bingo hall located within city limits? Yes [g] No CJ If "No," indicate township in which bingo hall is iocated <br /> .!f1r~lif'.I!l~~.II!'i~~I~ll€<<!~Y~l~'!!I!~I1.nl~li!I~gi1!l~lfll1!il~;lj}\lilli!ji\!li!i~1!jl[ig!!Jjii~jl!;illijlll!Jljiljj!lj~lll <br /> 4, Name oflegalgwner of bingo h~ property Phone Ll- <br /> S. -0 rtl,;tJ <br /> Business Mail g Address State <br /> , <br /> J' <br /> 5. Names of all owners, officers, lrectors, partners, managers and supervisors <br /> (each person named must fill out a separate Bingo Hall Personnei Information form, LG315 and Affidavit, LG316) <br /> a.tfj,ht7r1- t: J.>tfJt:if,/R<<:",-4-I'f, k. <br /> b. g. I. <br /> . c. h, m, <br /> d. i. n. <br /> e, j, 0, <br /> lWml.B1Im41~1,~11%.illli.~1.ttlllf..{i~il%lllltlitll!r~1Iltill~f~~1~lfiilfl*~'w.l111111I!f!1~ilil <br /> 6,' ){V $~4-..>"l L(5'e. ,07<.:IO:if <br /> I I Sole proprietorship I I Partnership I X I Corporation A: L ;f/ <br /> ljlm!msl~m~'l..iwl!.flW1f4Itl.$t\lillrftillIl11l1fjflflwR.f.'~ll;liliw*[lftil1j1{ <br /> 7. Have/do any persons listed in items 4 and 5: Yes No <br /> a. been convicted of a felony? D ~ <br /> b, eVer been convicted of a crime involving gambling? D .kJ ; <br /> c. ever held a bingo hall license previously in Minnesota? D "0 <br /> d. oWe delinquent taxes in excess of $500 as defined in Minnesota Statutes section 270.72? D ~ <br /> e. ever been convicted of assault, criminal violation involving the use of a firearm, or making D ~ <br /> terroristic threats? <br /> f. after demand, not filed tax returns required by the Minnesota Commissioner of Revenue? D !kJ <br /> . 8. Are any of the individuals listed in items 4 or 5, or a person hoiding a financial or managerial interest <br /> in the bingo hall, or affiliate thereof _ D 1kI <br /> . a licensed distributor or'affiliate of the distributor under section 349.161? <br /> . a licensed manufacturer or affiliate of the manufacturer under section 349.163? D tzg <br /> . an affiliate of a Wholesale distributor of alcoholic beverages? n txl <br />