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<br /> LG315 Minnesota Lawful Gambling <br /> (R&y.(10r'31~ Bingo Hall Personnel Information <br /> DgQ)fI'qm:~ifl:q]ITLlfrtllwl~J.itit.lf~ftlllll.1m~rnljllllt.ll~!1TIi;lrl.~t!111!!11!11;,111~li!1,ill!l;j'illl;l!il:!i <br /> 1. Name ~ngo hall _ ~ Phone <br /> 8-/ ///'/~l.i MI/ <&/,;{ ) b3/ /7;)4 <br /> ).y. .l/ M /; ~ <br /> . Address Cily Slale Zip code <br /> S 7 76' (t7,vLr-t2-/I~ ,4;-.( .4//-/0/;;;/1<; -#/// ~S-// .:2-- <br /> g&.J1fl'-~1!r!::(f)~~i.lal'I~]!tj!;11!W~;il~j{lI;11\.!tl~it!11It1.!1!lmjl!!iltifil@i1It\t!ll;!!;ij!!jltlll!ill!!lil!lliillljii';llliil'il,lijijjjjjilli;i <br /> 2. Last Name First Name;!- Full Middle Name <br /> -;)3-/.1-. <br /> Dates of Service U,S. Citizen Yes No <br /> If no, fill in re istration number: <br /> 6. Your position with bingo hall (check one) 0 Sole Proprietorship C Director 0 <br /> 0 Partner go Corp. Officer 0 <br /> Work phoneWld, ) (j3J9tJ60 Your du iesi- D <br /> ,i//c '" <br /> 7. Employment record for past 1 0 years (include periods of unemployment 0 , <br /> Employer Address Type of Business Position Held Dates of Employment <br /> SI>/;::- -I. ,/, 5~/-I /117 r J?,,/4;{fAP .5/,yy / IrS / <br /> . '5/,t'Jj Nn,h... Y '''''''<;Jwi''/'((f h T?:-I' J);1h)- <br /> ,It (?Z< .4;v ;~p 5<- <br /> . , <br /> j/~ 407(7 fCr.-/-4' .,to"yo 1'0 Ii::. <br /> B. Place of residence for past 10 years <br /> Address City State Zip code Dales of Residence <br /> . 1..t;3 s-7 I/" / ~.5C I,/"".I';k M.tr .PP'P//"// ,-0//// -5;4"'<L-I- 7 /777' <br /> 9. Criminal history statement (except petty misdemeanors). If none, write 'none." <br /> Dale Charge C::y and Stale Disposition <br /> d<-:J P't??- <br /> 10. Name, address, and license or exemption # of any organization you be'ong to which conducts lawful gambling. <br /> tf none, write "none." <br /> Organization License or Exemption Number <br /> Address ~ CJ r?-" t:/../ Zip Code <br /> City State <br /> Organization License or Exemption Number <br /> Address City State Zip Code <br /> <br /> J ded8ls thai this applicalkm ;s CZJ"ecl and romp/ele to the best of f77J' .'.:now/edge and beDel. I understand thar <br /> false and misfeading answet's are grounds/or denial of Rcense cr :e'rOcation of any licenses granted. <br /> YO~#e _4f~;6;d4/;L Date <br /> . tJ' ~ 9- /Y'/2 <br /> - <br /> Attach this form to Bingo Hall PersonneiAffidavit, 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 <br />