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<br />STATE OF MlNNFSOTA <br />GAMBLING CONTROL BOARD <br />~:12/09/99 BINGO HALL PERSONNEL INFORMATION - LG315 <br /> <br />LICENSE NUMBER: BH013 EFFECTIVE DATE: 06/01/00 EXPIRATION DATE: 05/31/01 <br /> <br />EMPLOYER INFORMATION <br /> <br />Name of Bingo Hall: Pot O'Gold <br />DBA: <br />Address: 3776 Connelly Arden Hills, MN 55112 <br /> <br />Phone Number: 651-631-1724 <br /> <br />APPLICANT INFORMATION <br /> <br />Last Name <br />Siedow <br /> <br />First Name <br />Goldie <br /> <br />Full Middle Name Maiden Name Previous Name <br />Katherine Johnson N/A <br /> <br />Social Security Number <br />471-32-4299 <br /> <br />Home Address: 3873 114th LN NE Blaine, MN 55449 <br /> <br />Home Phone:612-783-1840 <br /> <br />Driver's License # <br /> <br />State of Issue <br /> <br />S-300-285-461-432 MN <br /> <br />..te of Birth Birthplace-City <br />"'/09/34 Parkers Prairie <br /> <br />State Province <br />MN <br /> <br />Full First Name of Spouse <br />N/A <br /> <br />MILITARY 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 />OwnerlPartner <br /> <br />Duties <br />None <br /> <br />ADDmONAL INFORMATION NOT PREVIOUSLY SUBlVIlTnill <br />Attach additional sheets if necessary to resJ>l"lnd to the following information. Be sure you sign the additional sheets. <br /> <br />, , <br /> <br />Ust other employment you current <br />List the Employer Name, Addr yment and Type of Business: <br />-=r <br />. _.le__'_III G..,\cl..<!...... Do"t\a..r-i: 11~'f-I\;:'D. <br />Ust the MN Sales & Use Tax # for esota:, , SV\,D..<:.I( 8a-I- <br />" 4-1-i/37711 <br />Il It ~ <br />tit any Criminal History (Except Petty Misdemeanors). If None, Write "NONE". NON E <br /> <br /> <br />List Name, address and license or exemption # of any organization you belong to which conducts lawful gambling: <br />