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<br />.' <br /> <br />Minnesota Lawful Gambling <br />.ingo Hall License Renewal Application - LG300 <br /> <br />License number: <br />Effective date: <br /> <br />8H013 <br />6/1/2003 <br /> <br />Name of applicant: <br />Expiration date: <br /> <br />Pot O'~~ <br />5/31/1004- <br /> <br />Personnel: <br />The owner of the premises must be the lessor of the bingo hall. Subleases are not allowed. <br /> <br />. Verify that the personnel list below is complete and accurate, and contains all owners, officers, managers, <br />directors, supervisors, and persons or entities with a direct or indirect finandal interest of five percent or more, <br />as prescribed by board rule. <br />. Add new personnel not listed and submit an LG315. <br /> <br />Name <br />Goldie Katherine Siedow <br /> <br />Role <br />Owner <br /> <br />Duties <br />None <br /> <br />. <br /> <br />Oath <br />1 declare that any lease agreements between the <br />~d=~:~~: ::::: ~~:~=.and complete bingo hall licensee and lawful gambling organizations <br /> <br />I will familiarize myself with the laws of the state of will specifically identify any goods or services that the <br />organization is required to purchase from the lessor or <br />Minnesota and rules of the Board governing gambling <br />and agree, if licensed, to abide by those laws and a third party vendor, and that all goods and services <br />furnished as a part of the lease agreement will be <br />rules, induding amendments to them. valued at their fair market value. <br />I declare that I am qualified under the terms of <br />Olanges in the information submitted in this <br />Minnesota Rules, part 7862.0010, subpart 3, to be pl' t' '11 b bm'lted' .t. to th Be d <br />I. sed b' hall d '11 b'de b th ap lca IOn WI e su I In wn Ing e ar <br />lcen as a Ingo an WI a lye , . . <br />est. ti t f rth. M' ta R I rt and local Unit of government Within ten days after the <br />r nc ons se 0 In Inneso u es, pa ch <br />ange occurs. <br />7862.0010, subpart 4. <U f)..' .r f) , <br />7L~~,I".d~ Date: fg-IS-(J~ <br />Signature ot chief executive officer <br />r,...D I J. I ~ K....s; p ,t 0 uJ <br />Name (please print) <br /> <br />Mail Renewal Application to Gambling Control Board, with attachments. <br /> <br />LG300 - Bingo Hall License Renewal Application Mail to: <br />LG302 - Bingo Hall Occasion Ust <br />LG315 - Bingo Hall Personnel Information <br />. Resolution - Local unit of government approval <br />resolution (dty or CDUnty); and <br />Check for , payable to "State of <br />Minnesota" (fees are cons' ed earned and are not _ <br />prorated or transferrable) ,$S, <JOt> 00 dOJ.J.J LhGSl(j Q... - \ Ul0 'IeOS- <br /> <br />Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville, MN 55113 <br />