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<br />lG315 Minnesota Lawful Gambling
<br />I"'v, ('0011001 Bingo Hall Personnel Information
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<br />1, Name :;"n9o hall Phone
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<br />Address , City State Zip code
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<br />2. Last Name First Name,/- Full Middle Name I Previous or maiden name
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<br />Dates of Service U.S. Citizen
<br />If no, fill in re istration number:
<br />6, Your position with bingo hall (check one) 0 Sole Proprietorship C Director
<br />o Partner g Corp. OHicer
<br />Work phone(,6IJ,) '153/9/760 Your du ies:!
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<br />7, Employment record for past 10 years (include periods of unemployment 0
<br />Employer Address Type of Business Position Held Dales at Employmenl
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<br />8. Place of residence for past 10 years
<br />AddrBss City State Zip code Dates of Residence
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<br />9, Criminal history statement (except petty misdemeanors), If none, write "none."
<br />Dale ChaIge Ci:y and State Disposition
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<br />1 O. Name, address, and license or exemption # of any organization you be'ong to which conducts lawful gambling,
<br />ff none, write "none."
<br />Organization license or Exemption Number
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<br />Address City State Zip Code
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<br />Organization license or Exemption Number
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<br />Address Ciry State Zip Code
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<br />I dedare that this application is Ct1rrecl and romp/elB to rhe best of my ,(,now/edge and beRel. I understand that
<br />false and misleading answers are grounds lor denial of Pcense (X :eKlcatJon 01 any licenses granted.
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<br />Attach this form to Bingo Hall Personnel Affidavit, lG316
<br />Mail to: Department of Gaming. Gambling Control Division
<br />Rosewood Plaza South, 3rd Floor
<br />1711 W. County Road B
<br />Rosevllle, MN 55113
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