Laserfiche WebLink
<br />~. <br /> <br />STATE OF MINNESOTA <br />GAMBLING CONTROL BOARD <br />BINGO HALL PERSONNEL INFORMATION - LG315 <br /> <br />i <br /> <br />'RINTED:12/01/98 <br />LICENSE NUMBER: BH013 <br /> <br />. <br /> <br />EFFECTIVE DATE: 06/01/99 EXPIRATION DATE: 05/31/00 <br /> <br />EMPI:;OYER-lNFORMATION <br /> <br />Name of Bingo Hall: Pot O'Gold <br />DBA: <br />Address: 3776 Connelly Arden Hills, MN 55112 <br /> <br />Phone Number: 612-631-1724 <br /> <br />APPLICANT Th'FORMA TION <br /> <br />Last Name <br />Siedow <br /> <br />First Name <br />Goldie <br /> <br />Full Middle Name Maiden Name <br />Katherine Johnson <br /> <br />Previous Name <br /> <br />N/A <br /> <br />Social Security Number <br />471-32-4299 <br /> <br />Home Address: 3004 Jamley Ave N Lake Elmo, MN 55042 <br /> <br />Home Phone:612-777-2971 <br /> <br />Driver's License # <br /> <br />State of Issue <br /> <br />S-300-285-461-432 MN <br /> <br />Date of Birth Birthplace-City <br />06/09/34 Parkers Prairie <br /> <br />State <br />MN <br /> <br />Province <br /> <br />Full First Name of Spouse <br />N/A <br /> <br />. <br /> <br />:\lILIT ARY INFORMATION <br /> <br />CITIZENSHIP <br /> <br />Branch of Military Service <br />N/A <br /> <br />Dates of Service <br />N/A <br /> <br />US Citizen <br />T <br /> <br />EMPLOYMENT STATUS WITH THIS EMPLOYER <br /> <br />Your position <br />Owner/Partner <br /> <br />Duties <br />None <br /> <br />ADDITIONAL INFORMATION NOT PREVIOUSLY SUBMITTED <br />Attach additional sheets if necessary to respond to the following information. Be sure you sign the additional sheets. <br /> <br />. jt.~"fY\'-""/"'~'fV"'- "'. ~..<"._,.."., '~!'IJ'.","'J'i';,.._.~..~.~'8 <br />LIst other employment you c~ently 110111. .;;."':,.,,,. t <br />. List the Employer Name, Ar:!SS,:~~sit:onheJd; ::g~~5. .'. ..oyment and Type of Business: <br /> <br /> <br />LIst the MN Sales & Use Tax /I for-a1I'Busmesses-owned'ffi"Mmnesota: <br /> <br />List any Criminal History (Except Petty Misdemeanors). If None, Write "NONE". ,'- NON l:. ' , <br /> <br />. <br /> <br />List Name, address and license or exemption /I of any organization you belong to which conducts lawful gambling: <br />