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Minnesota Lawful Gambling flingo Hall License Renewal Application - lG300 Bingo Hall Information License number: 8H013 Name of bingo hall: DBA, if applicable: Street address: Oty, state or province, postal axle: Phone number (with area code): Mail ing address (if different than above): Fee Check # Effective date: Pot O'Gold 6/1/2003 Expiration date: ~665 5/31/'2901 3776 Connelly Arden Hills, MN 55112 (651) 631-1724 Fax number (with area code): Type of Business (sole proprietorship, partnership, corporation, limited liability company, finn): Sole Proprietorship Minnesota Tax Identification Number: 1123411 local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application: On behalf of the dty, I acknowledge that this application wil be forwarded. to the ",propriate city offda~, the dty must pass a resolution Specifically approving or denying this application, and a copy of the resolution wil 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 acknowledge,. by this signature, awareness of this application and tha the township has no authority to deny or approve an application. .7=~Hi~ N<rne of township: (SignabJre of township official acknowledging application) (Signature of dty personnel receMng application) Title Date---1---1_ Hie (111 -rJ1L~ Date'?::) 10 I> L Forthecountv: On behalf of the county, I acknowledge that this app6cation wi. be forwarded to the appropriate county olfidais, the county must pass a resolution specifically approving or denying this application, and a copy of the resolution wil be forwarded to the ",plying organizatio n. N<rne of county: (SignabJre of county personnel receiving application) Hie Date---1---1_ Q.Jestionson this form should be directed to the Gambling Control Boad at 651-6394000. Hearing impaired indMduals using a TTY may can the Minnesota RelaySerW::e at 1-800-627-3529 and ask to pla:::e a can to 651-639-4000. This pubncation win be made available in alternative format (i.e. large print, Braille) upon rEquest. The inforrration requested on this form (iI1d any att((:hrrents) WU be used by the Ganbting Control Board (Board) to ~ine )QLlr quaUficatiOnS to be in~lve:l in la.vful gambling activities in ta, ald to assist the Board in conducting a background investigation of ou have the right to refuse to supply the infOlmation reques:t-ed; however, if you refuse to supply this Infcmnation, the Boa-d mat not be able to detennine your qu..fiC<tions iJld, as a consequence, may refuse to issue you a license_ If you supp Iy the information requested, the Board wi1 be <ble to process your application. Your name a1d ocIdress \.'All be public irformation when received by the Board. ~ the other information that you prOlMe wiD be about you unitl the Board issues your license. When the Board issues your license,. aU of the information that you have provided to the Board in the process of app lying for your rlCense wiD become p ubUc.. If the Board does not issue you a license, all the information you hall'e provided in the process of applying for a license remains private, with the except! on ci your name and address which will remain publiC. Private data about you are available onty to the following: Board members, st:tf of the Board whose W)l"k. aSSignment requires that they hafe aIess to the information; the Minnesota Department of Public Sarety; the Minnesota Attorney Gel"l6'"al; the Minnesota CommiSSiOn<<s of Administration, Finance, and Revenue; the Minnesota legis! ative Auditor I national and interO<tiOn~ ganbling regulatory ageocies; anyone pursuant to court el'"(fer; other individuals and agendes that are specifICally authorized by state or feda"al law to have access to the infonnation; individuals and agencies for whiCh law or lEg ~ order aulhortzes a new use or sharing of informa:ion cfter thisnctice was given; ald anyone with your written consent.