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<br /> ----- -- <br /> - 'I <br /> STATE OF MINNESOTA I <br /> GAMBLING CONTROL BOARD <br /> BINGO HALL PERSONNEL L'IFORMATION - LG3I5 e. <br />PRINTED: 07/19/96 PART 1 OF 2 <br />LICENSE NUMBER: BH013 EFFECTIVE DATE: 06/01/97 EXPIRATION DATE: 05/31/98 <br />NAME OF BINGO HALL Pot 0' Gold BINGO HALL PHONE NUMBER 612-63I-I724 I <br />STREET ADDRESS OF BINGO HALL 3776 Connelly <br />CITY, STATE ZIP CODE Arden Hills MN 55H2 Social Security Number I <br />Last Name First Name Full Middle Name Previous Name Maiden Name <br />Siedow Goldie Katherine N/A Johnson 471-32-4299 <br />Home Address City State Zip Code Home Phone I <br />3004 Jamley Ave N Lake Elmo MN 55042 612-777-2971 <br />Driver's License 1/ State of Issue DOB Birthplace-City State Full Name of Spouse I <br />S-300-285-46I -432 MN 06/09/34 Parkers Prairie MN N/A <br />Branch of Military Service Dates of Service US Citizen Length of Residence in MN <br />N/A N/A T Life I <br />Your position with bingo hall Duties <br />Sole Proprietor None I <br />EMPLOYMENT RECORD FOR PAST 10 YEARS <br />Employer Address Position Held Type of Business Dates of EmPloym__ <br />Pot 0' Gold Owner Bingo Hall/Check Cas 1987 - present <br />3776 Connelly Arden Hills MN <br />Lake Elmo Custom Molds Owner Custom Molds 1960 - 1991 I <br />466 Kalmia Lk Elmo MN <br />PLACE OF RESIDENCE FOR PAST 10 YEARS <br />Address City State Zip Dates of Residence I <br />3004 J amley Ave N Lake Elmo MN 55042 1960-Present <br />CRIMINAL HISTORY STATEMENT (EXCEPT PETTY MIDEMEANORS). IF NONE, WRITE "NONE". I <br />None <br />NAME, ADDRESS, AND LICENSE OR EXEMPTION 1/ OF ANY ORGANIZATION YOU BELONG TO WHICH I <br />CONDUCTS LAWFUL GAMBLING. <br />Organization License or Exemption Number Title <br />None E3HOIJ Sore P... 0 'w " e. to Y' I <br />ADDITIONAL INFORMATION: 1 <br /> I <br /> I <br /> .. <br /> )jJ. .:'1--! -<i '1 I <br /> ---------- ------------- <br />