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STATE OF MINNESOTA GAMBLING CONTROL BOARD RENEWAL APPLICATION FOR BINGO HALL LICENSE - LG300 . PRINTED:12/09/99 LICENSE NUMBER: BH013 NAME OF APPLICANT: Pot O'GoId 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. /IoiJ~ ~ J( ~ ~-I"'~ Signature of the Chief Executive Officer . / - I X - ~ 000 Date Signed Reouired Attachments .j LG302, Bingo Hall Occasion List; .j LG315, Bingo Hall Personnel Information; .j Loca1 Unit of Government resolution of approval; and .j 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, Braille) upon request. Hearing impaired individuals using a TIY may call the Minnesota Relay Service at 1-800-627-3529. The infonnation requested on this fonn (including any attachments) will be used by the Gambling Control Board (GCB) to dctcnnine your e qualifications to be involved in lawful gambling activities in Minnesota, and to assist the GCB 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 infonnation. the OeB may not be able to determine your qualifications and, as a consequence, may refuse to issue you a license. If you supply the infonnation requested, the GeB will be able to process your application.