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. . Minnesota Lawful Gambling Bingo Hall License Renewal Application - LG300 Fee Check # Bingo Hall Information License number: BH013 Name of bingo hall: DBA, if applicable: Street address: City, state or province, postal code: Phone number (with area code): Mailing address (if different than above): Type of Business (sole proprietorship, partnership, corporation, limited liability company, firm): Sole Proprietorship Minnesota Tax Identification Number: 1123411 Effective date: 6/1/2001 Expiration date: 5/31/2002 Pot O'Gold 3776 Connelly Arden Hills, MN 55112 (651) 631-1724 Fax number (with area code): Local Unit of Government Acknowledgment Ifthe gambling premises is within city limits, the city must sign this application: On behalf of the city, I acknowledge that this application will be forwarded to the appropriate city officials, the city must pass a resolution specifically approving or denying this application, and a copy of the resolution will be forwarded to the applying organization. If the gambling premises is located in a township, both the county and township must sign this application: For the townshiD: On behalf of the township, I acknowiedge, by this signature, awareness of this application and that the township has no authority to deny or approve an application. Name of township: Name of city: Arden Hills i~pe~~el~CatiOn) (Signature of township official acknOWledging application) Title Date----1----1_ Title D 'N ~@3vJ!@L DateDl/fu l)) For the county: On behalf of the county, I acknowledge that this appiication wili be forwarded to the appropriate county officials, the county must pass a resolution specifically approving or denying this application, and a copy of the resolution will be forwarded to the applying organization. Na me of county: (Signature of county personnel receiving application) Title Date----1----1_ Questions on this form should be directed to th e Gambling Control Board at 651-639-4000. Hearing impaired individuals using a m may calf the Minnesota Relay Service at 1-800-627-3529 and ask to place a call to 651-639-4000. This publication will be made available in alternative format O,e. large print, Braille) upon request. The information requested on this form (and any attachments) will be used by the GambUng Control Board (Board) to detemine your quallncatlons to be involved In lawful gambling activities in Minnesota, and to ssist the Board in conducting a background Investigation of you. You have the right to refuse to supply the information requested; hovwever, if ~u refuse to supply this information, the Board may not be able to determine your qualincations and, asa consequence, may refuse to issue you a license. If you supply the information requested, the Board will be able to process your application. Your name and address wiU be public information when received by the Board. All the other information that you provide will be private data about you unltl the Board issues your license. When the 6::>ard Issues your license, all of the information that you have provided to the Ebard in the process of applying for your license will become public. If the Board does not issue you a license, all the Information you have provided in the process of applying for a license remains pri\iclte, with the exception of your name and address which will remain public. Private data about you are available only to the following: Board members, staff of the Board whose work assignment requires that they have access to the Information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of .Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and Intemational gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are spedfically authorized by state or federal law In have access to the Information; Individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with yourwrltten consent.