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<br />Minnesota Lawful Gambling <br />Bingo Hall License Renewal Application - LG300 <br /> <br />. <br /> <br />License number: <br />Effective date: <br /> <br />BH013 <br />6/1/2003 <br /> <br />Name of applicant: <br />Expiration date: <br /> <br />Pot O'~~ <br />5/31/2Q04... <br /> <br />Personnel: <br />The owner of the premises must be the lessor of the bingo hall. Subleases are not allowed. <br /> <br />. Verify that the personnel list below is complete and amJrate, and contains all owners, officers, managers, <br />directors, supervisors, and persons or entities with a direct or indirect finandal interest of fIVe percent or more, <br />as prescribed by board rule. <br />. Add new personnel not listed and submit an LG315. <br /> <br />Name <br />Goldie Katherine Siedow <br /> <br />Role <br />Owner <br /> <br />Duties <br />None <br /> <br />Oath <br /> <br />. <br /> <br />I declare that any lease agreements between the <br />I declare that this application is correct and complete <br />In the best of my krowledge and belief. bingo hall licensee and lawful gambling organizations <br />I will familiarize myself with the laws of the state of will specifically identify any goods or services that the <br />Minnesota and rules of the Board governing gambling organization is required to purchase from the lessor or <br />and agree, if licensed, In abide by those laws and a third party vendor, and that all goods and services <br />furnished as a part of the lease agreement will be <br />rules, induding amendments In them. valued at their fair market value. <br />I declare that I am qualified under the terms of <br />Changes in the infonnation submitted in this <br />Minnesota Rules, part 7862.0010, subpart 3, to be <br />1- nsed b. hall d "II b.de b th application will be submitted in writing to the Board <br />Ice asalngo anWlal ye " .. <br />t. ti t f rth. M' ta R I rt and local unit of government within ten days after the <br />res nc ons se 0 In Inneso u es, pa ch <br />ange oa:urs. <br />7862.0010, subpart 4. ilJ f)..' J! /J . <br />~ ~ l#5= ~ tf"d.......u.J Date: /.;!. -/5- o8f.... <br />Signature of chief executive officer <br />G-D I J. I ~ K....5; l> Aloc-J <br />Name (please print) <br /> <br />Mail Renewal Application to Gambling Control Board, with attachments. <br /> <br />LG300 - Bingo Hall License Renewal Application Mail to: <br />LG302 - Bingo Hall Occasion List <br />LG315 - Bingo Hall Personnel Information <br />Resolution - Local unit of government approval <br />resolution (city or county); and <br />Check for,. payable to "State of <br />Minnesota" (fees are consi ed earned and are not _ <br />prorated or transferrable) $S, .<tOO ~ 6i1luJ GQJ)O.Q... - \ w 0 1c~ <br /> <br />Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville, MN 55113 <br /> <br />. <br />