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Minnesota Lawful Gambling Bingo Hall License Renewal Application - lG300 Fee . Check # Bingo Hall Information License number: 8H013 Name of bingo hall: DBA, if applicable: Street address: Oty, state or province, postal rode: Phone number (with area code): Mailing address (if different than above): Type of Business (sole proprietorship, partnership, corporation, limited liability company, firm): Sole Proprietorship Minnesota Tax Identification Number: 1123411 Pot O'Gold Efferovedate: 6/1/2003 Expiration date: ~665 5/31/'J:004 3776 Connelly Arden Hills, MN 55112 (651) 631-1724 Fax number (with area rode): Local Unit of Government Acknowledgment If the gamb6ng premises is within city limits, the city must sign this application: On behalf of the dty, I ackrowledge that lIlis application wil be forwarded to the appropriate city offdais, the dty must pass a resolution specifically approving or denying this application, and a copy of the resolution wil be fOrwarded to lIle applying organization. N/~d~HiW (Signature ot at)' personnel receiving application) Hie Gt( -rJ1L~ Date\h.i\ Ie, ,61- If the gamb6ng premises is located in a township, both the a>unty and township must sign this application: For the townshiD: On behalf of the township, I acknowledge, by this sgoature, awareness of lIlis application and that the township has no authority to deny or app""" an application. NiJ'lle ot township: . (Signature of township official acknowledging application) Title Date---1---1_ For the county: On behalf of the county, I acknowledge that this appncation wiR be forwarded to the appropriate county offiaals, the county must pass a resolution spedfically approving or denying lIlis application, a1d a copy of the resolution wil be forwarded to the applying organization. NiJ'lle of county: (SignabJre of county personnel receiving application) Title Date---1---1_ Questions on this form should be directed to the Gambling Control Boad at 651-639-4000. Hearing impaired in::lividuals USing a TTY may caU the MInnesota Relay SErVice at 1-800-627-3529 and ask to pla:e a call to 651-639-4000. This publiCation will be made available In altErnative tonnat (i.e. large print, 8r.ai1le) upon request-The information rEquESted on this form (m any atta:hrrents) wit be used by the GaTlbling Cbntrol Board (Board) to determine your qualifications to be in\rdved in la.vful gambling activities!n Minnesota, and to assist the Board in COnducting a bac:kgmUld investigation of 'ttlu. You have Ule right to refuse to supply the infonnation requested; however, if ~u refuse to supply this information, the Bocrd mer; oot be able to detennine your qualifiC<tions ir"Id, as a consequence, may rEfuse to issue you a license. If you supp tv the infOlTflation requested, the Board will be cb Ie to process your application. Your name ..,d crldress IMII be public information when received by the Board. All the other information that 'rOU provide win be about you unit! the Board issues your license. W1len the Boa-d issues 'yOur license, aU of the information that you have provided to the Board in the process of applying tor yotK license will berome public. If the Board does not issue you a license, an the infQrrretion you hale provided in the process of applying for a license remains private, with the elCl:epti on r:J your name and address which will remain pubfic.. Private data abou: you are available only to the following; Board members, slitf of the Board whose work assignment reqUire; that they h<we a:cess to the infonnation; the Minnesota Department of Public Salety; the Minnesota Momey Ge/"lEfal; the Minnesota CommssloOffS of Administration, Finance, and Re~mJe; the Minnesota I..egislitive htditor, national and intern(tion<j ganbling regulatory agencies; anyone pursuant to murt a-der; other indi\.1duas: and agencies that are spedfJCa11y authortzed by state or federal law to halle accESS to the infOlTflation; individuals: and agencies for which law or legal order authorizes a new use or sharing of Irlform<tion <Iter this odice was given; ald anyone wth your written consent. .