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<br /> . FOR OFFICE USE ONLY <br /> Fee <br /> Date_ <br /> Chk Initial_ <br /> LG300 <br /> (Rov.1013019O) Minnesota Lawful Gambling License # <br /> . Bingo Hall License Application - Part 1 <br /> (See instructions for completion of tllis application) tp,/., /t1{1~ <br /> Is this application for a new license, or a renewal? 0 New ~enewal .flw - ~ <br /> Y/913S- <br /> <br /> 1, Name of bingo hall t3 P'V~o ~\(.\ \ \ Bingo Hall Phone County (where hall is located) <br /> C\R:Dt:;/0 \.1, \ \ So ((,/;1) 4>3/-/3/J" ;<{:)((JSciY <br /> Slreet address ~hall \ City or Township where hall is located SLale Zip code <br /> 3'11/..p Oo'JNI.;:;\ Y CUe. C-:li2.UI:;.-.J NIII ':. (nW -55 In. <br /> 2. Mailing address of bingo hall City Slate Zip code <br /> 3i7(p CONr.J~/I'1 (.JUI.;:; PI R.U<::><J )-1, II s fnlV 66//:).- <br /> 3. Is the bingo hall located within ci~ limits? Yes No CJ II 'No," indicate lownshlp in which bingo hall is located <br /> <br /> 4. Name of legal owner of bingo hall property Phone -+ 8 8 8:2 is <br /> w C\ I,....S 'n J:\N.i) r-l ~ s. ac... I AI C .s ( &,t,a) - <br /> Business Mailing Addrf;{ City p ~ Slate . Zip Code <br /> /0/3 T ON-r ~T '::;" Rv rJJ;U '65/0..3 <br /> . <br /> 5. Names of all owners, officers, directors, partners, managers and supervisors <br /> (each person named must fill oul a separate Bingo Hall Personnel Information form, LG315 and Affidavit, LG316) <br /> a. ~OlJ Il~ u.J f-::\\.-.~ \4 f. k, <br /> . b. ::ro~ ~ w A l- ~ 14 g, L <br /> cGoldle ':; l0dow h, m, <br /> d, i. n. <br /> e, j. o. <br /> <br /> 6. I ,........... -r;;:'rporation <br /> - L-.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 d <br /> b. ever been convicted of a crime Involving gambling? D 0'" <br /> c. ever held a bingo hall license previously in Minnesota? [2] D <br /> d. OWe delinquent taxes in excess of $500 as defined in Minnesota Statutes section 270,72? D [0'" <br /> e. ever been convicted of assault, criminal violation involving the use of a firearm, or making D [!j" <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 hems 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 manufacturer or affiliate of the manufacturer under section 349.163? D [0" <br /> .-. <br />