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<br /> FOR OFFICE USE ONLY <br /> 1 Fee <br /> Date_ <br /> LG300 Chk Initial <br /> (R9'I.10l30f90) Minnesota Lawful Gambling License # <br /> . Bingo Hall License Application - Part 1 <br /> (See instructions for completion of this application) IP/.- / c1rJ '?!!-- <br /> Is this application for a new license, or a renewal? 0 New ~enewal ~- ,~ <br /> W993~ <br /> <br /> 1. Name 01 bingo hall i3IN~o l-L~ 1\ Bingo Hall Phone County (where hall is localea) <br /> C\R:Dt:;;~ W \ \ \.l;. ({,j'~) ip3J-/alt( j(f:J(I1SciY <br /> Street address ~ hall \ City or Township where hall is located State Zip code <br /> 31'10 O,vN,,;\ 1,1 Cue;. r-JR.ul;;;<.i J.ldl >;" /'rI1V -5S11~ <br /> 2. Mailing address of bingo hall City Stale Zip code <br /> 377(, CONIJ~/i-; /JUl; PI {(.uoJ I-I, \1 S- ('fliV 66/1J.. <br /> 3. Is the bingo hall located within ci~ limits? Yes No c=J If "No: indicate township in which bingo hall is located <br /> <br /> 4. Name at legal owner of bingo hall property Phone ~88 &is <br /> Lur:4I-'Sh !=\A/1) (.:J~S.Oc...IAII:.s (~Ia) - <br /> Busin'ess Mailing A~r~ S:,iCity PAul Stale . Zip Code <br /> /0/3 ON' '<:::,l" m;u '05/0.3 <br /> " <br /> 5. Names 01 an owners, officers, directors, partners, managers and supervisors <br /> (each person named must fill out a separate Bingo Hall Personnel Information form, LG315 and Affidavit, LG316) <br /> a. Lou Il~ LU ~l,...~ t-\ I. k, <br /> . b. :r oh ^-J w A I.- ~ 1.J g. I. <br /> c C;ulcl It:: 'S, l~dow h. m. <br /> d. i. n. <br /> e. j o. <br /> <br /> 6. I 1/ -r;;;:'rporation <br /> I I Sole proprietorship I I Partnership <br /> <br /> 7. Have/do any persons listed in items 4 and 5: Yes No <br /> a. been convicted of a felony? D 0 <br /> b. ever been convicted of a crime involving gambling? D 0 <br /> c. ever held a bingo hail license previously in Minnesota? CEI D <br /> d. owe delinquent taxes in excess of $500 as delined in Minnesota Statutes section 270.72? D [0" <br /> e. ever been convicted of assauit, criminal violation involving the use of a firearm, or making D 6 <br /> terroristic threats? <br /> . f. after demand, not filed tax returns required by the Minnesota Commissioner of Revenue? D ~ <br /> 8. Are any of the individuals listed in items 4 or 5, or a person holding a financial or managerial interest <br /> in the bingo hall, or affiliate thereof - D []2( <br /> a licensed distributor or affiliate of the distributor under section 349.161? <br /> . a licensed nanufacturer or affiliate of the manufacturer under section 349.163? D [0" <br /> __.L__ <br />