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<br /> FOR OFFICE USE ONLY <br /> . Fee <br /> Oate_ <br /> LG300 Chk Initial I <br /> (Aerv.1CV3019Oj Minnesota Lawful Gambling license # <br /> . Bingo Hall License Application - Part 1 <br /> (See instructions for completion ofthis application) <br /> Is this application for a new license, or a renewal? i:2J New 0 Renewai <br /> ;i~l(fY;0II~~~ltiil'qljlt~~t~,~~~!il%ll1i'[Jl~fJ!]~&lii\jlltill~1~i*;tfuli!ttl;ii!*ltl;il1*llflllililltl1ifiti!11ttll!1\It.j~11ff!!lil111i!litlll!1;IJ!;ill;!;1;;i;i; <br /> 1. <br /> 2. City Zip code <br /> .rJ NY <br /> 3. is the bingo hall located within city limits? Yes I8J <br /> .'I!fll;"!1;~ln:~.IIWt~IIKlmQ~t~4jllg1g#;~'lnl~II;JIj~l~Itfl~;tilli!li!itilill~f;~111l~lf!!il!i!ri!i!i!11il1111!!!tl'li!!I!lil~l;li! <br /> 4. Name ollegalgwner of bingo hi property Phone L) <br /> ~ -: CPt/ , rG/dJ <br /> 4.v- <br /> Business Mail g Address State <br /> , <br /> cf' <br /> S. Names of all owners, officers, Irectors, partners, managers and supervisors <br /> (each person named must fill out a separate Bingo Hall Personnel Information form, LG315 and Affidavit, LG316) <br /> a. ;F),ht7 nl- t: htJP.h./b'C-</4->fI. k. <br /> b. 9. I. <br /> . <br /> c. h. m. <br /> d. i. n. <br /> e. j. o. <br /> !tfR~fm!l&..ll.I.l.l:if.llllllllwr{t.:'t.\ifiNw.lilll!it\ll{1;;i;i+tll!lt.rll1!i{'~f,;~;lr11fliilil1!1;i.l1 <br /> 6. J.lv 5'/0) tlS!!.- -p:J)(:JD:k <br /> g"Ufilmc~iW~X'~:'~:;:;:~::~'%\N%~0Wf%~'1;:;::%@"~~%\~~;;:~::~~"4i~\~$l%mwww', <br /> :.. .n~'>".m.";';.:;..: {?>~;:,~;;-:-}:~",::xn~~tt~J : ...ltdt*k,>>%@:~..~@fi..w1dfu1tA%TIH&Wi0J.m:t'W~:::*:mtt*ttt%t:if::fq%~d?1.w~~t~B*'tkdW@k*0~tdlli~~m!~tt~~t:;M~:m%i <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 E <br /> c. ever held a bingo halllicensa 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 [Sa <br /> . 8. Are any of the individuals listed in nems 4 or 5. or a parson holding a financial or managerial interest <br /> in the bingo hali, or affiliate thereof _ D ~ <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 0- <br /> . an affiliate of a wholesale distributor of alcoholic beverages? n 15<1 <br />