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<br />Minnesota Lawful Gambling <br />. Bingo Hall Personnel Information - LG315 (Renewal) <br /> <br />Bingo Hall Information <br />License number: BH013 <br /> <br />Effective date: <br /> <br />6/1/2001 <br /> <br />Expiration date: 5/31/2002 <br /> <br />Name of bingo hall: <br />DBA, if applicable: <br />Street address <br />City, state or province, zip code: <br />Phone number (with area code): <br /> <br />Pot O'Gold <br /> <br />3776 Connelly <br />Arden Hills, MN 55112 <br />(651) 631-1724 <br /> <br />Personnel Infomation <br />First name, full middle name, and last name: Goldie Katherine Siedow <br />Maiden name and/or previous name: Johnson <br />Social security number: 471-32-4299 <br />Home address: 3873 114th Lane NE <br />City, state or province,zip code: Blaine, MN 55449 <br />Home p~gp,e;')~ 783-184~ <br />Driver's license number and state or province of /!;i~.J S-300-285-461-432 MN <br />Birthdate and birthplace (city, state or province): 6/9/1934 Parkers Prairie, MN <br />Full name of spouse: <br />Branch and dates of miiitary service: <br />U.S. citizen: Y If "N", country of citizenship: <br /> <br />. <br /> <br />Criminal History except petty misdemeanors (since last application): <br />Date charged City/state where charges were filed <br /> <br />Disposition of the case <br /> <br />Current Role - List your current role (owner, officer, director, partner, sole proprietor, manager, supervisor, or person <br />or entity with a direct or indirect financial interest of five precent or more, as prescribed by Board rule): <br /> <br />Role: Owner Duties: None <br /> <br />New Employment - List any new employment you currently hold (since last application). List employer name, address, <br />position held, dates of employment, and type of business. <br /> <br />Minnesota Tax Identification Number - List any new number for businesses you own in Minnesota (since last application) <br /> <br />Organization Membership - List any organization names, addresses and license or exemption permit numbers, or any <br />excluded organization you have joined that conduct lawful gambling in Minnesota. <br /> <br />Questions on this form should be directed to the Gambling Control Board at 651-639-4000. Hearing impaired individuals using a TlY <br />may call the Minnesota Relay Service at 1-800-627-3529. This publication will be made available in altemabve fonnat (Le. large print, <br />8raille) upon request <br /> <br />. <br />