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STATE OF MINNESOTA GAtvtBLING CONTROL BOARD RENEWAL APPLICA nON FOR '.ED: 12/01197 BINGO HALL LICENSE - LG300 LICENSE NUMBER: BH013 NAME OF APPLICANT: Pot O'Gold OATH I declare that this application is correct and complete to the best of my knowledge and belief. I will familiarize myself with the laws of the State of Minnesota and Rules of the Board governing gambling and agree, if licensed, to abide by those laws and rules, including amendments to them. I declare that I am qualified under the terms of Minnesota Rules 7862.0010, Subp 3 to be licensed as a bingo hall and will abide by the restrictions set forth in Minnesota Rules 7862.0010, Subp 4. I declare that any lease agreements between the bingo hall licensee and lawful gambling organizations will specifically identify any goods or services that the organization is required to purchase from the lessor or a third party vendor, and that all goods and services furnished as part of the lease agreement will be valued at their fair market value. Changes in the information submitted in this application will be submitted in writing to the Board and local unit of government within ten (10) days after the change occurs. \ cJd>0l~~) e Signature of the Che xecutive Officer j-!Lf -czr Date Signed Reouired Attachments "fLG302, Bingo Hall Occasion List; "fLG315, Bingo Hall Personnel Information; "f Local Unit of Government resolution of approval; and "f License Renewal application fee of $2,500. Make Checks payable to "State of Minnesota", (Fees are considered earned and are not prorated or transferable.) Mail application and attachments to: Gambling Control Board Suite 300 S 1711 W, County Road B Roseville, MN 55113 Allow eight weeks for application processing This publication will be made available in alternative format (Le. large print, BraiHe) upon request. Hearing impaired individuals using a TTY may call the Minnesota Relay Service at 1.800-627-3529. . The information requested on this form (including any attachments) will be used by the Gambling Control Board (GCB) to determine your qualifications to be involved in lawful gambling activities in Minnesota, and to assist the GeB in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the GCB may not be able .to determine your qualifications and, as a consequence, may refuse to issue you a license. If you supply the information requested, the GCB will be able to process your application.