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<br />. <br /> <br />\. <br /> <br />. <br /> <br />Minnesota Lawful Gambling <br />LG315 Bingo Hall Personnel Information (No fee) <br />Complete this form if you are listed under "Owner lnformation~ on the LG300 Bingo Hall license Application. <br />Bingo Hall Information <br />Nameofbingohall <br />o -X oa <br />Personnel Information <br />1. first name <br />b-D \.\. €- <br />2. Maiden name <br />0: h .'\ <br /> <br />Pa9~ 1 of 2 <br />11/04 <br /> <br />< <br /> <br />DBA, ifapplicable <br />, . <br /> <br />Ucensenumber(,fis:suedl <br />BH- {; 13 <br /> <br /> <br />K~ <br /> <br />full middle name <br /> <br />Last name <br />. . <br /> <br /> <br />e.. i' 11-1. <2.- <br />PTe\'ious name <br /> <br />,sa... <br /> <br />Birth date <br />Q-3fL.- <br /> <br />b <br /> <br />_Partner <br /> <br />_Person or entity with a direct or indirect financial interest of five percent or more <br />Offar _Directc)( _Manager _Supervisor <br /> <br />BingoHallDuties;~ {) bJ E:- <br /> <br />6. Employment record for the past ten yeaf5. List the most QJrrent first, induding dates of unemployment or education (list smool and <br />address). If you owned a business in Minnesota.. inc:lude the Minnesota sales Tax and Use ID Number. <br />Employer/Sdtool Oty &: state or Province Position hekl Dates Type of Business MN Sales <br />Tax No. <br /> <br />Current: <br /> <br />Past: <br /> <br />], <br /> <br />Place of residence for the past. ten years. <br />Add""" <br />c,,,,,,to . 2,fr I :'J 11'i"lt' <br />.,;3t.....t\<I- (lct.iV'Hl~y <br /> <br />Oates of Residence <br />1<( 9'7 <br />~ Co y C~o:lc""S <br />/9 c,{J <br /> <br />Oty & state or province, Postal code <br />Le.VlP tll/e:.. Ala:.lrl"'~ tIll'l. <br /> <br />HoQ.. L'i 1(", r i"'l<; f"711. <br /> <br />Past: <br /> <br />8. Criminal history statement (except petty misdemeanors}. If none, write -none.- <br />Date charged Oty &. state or province where charges filed Description of charge <br /> <br />No <br /> <br />DispO:Sition of the case <br /> <br />9. List the name, address, and license or permit: number of any organUatioo you betong to which conducts lawful gambJing in Minnesota. If <br />none, write Knone." <br /> <br />Organization <br /> <br />Title {Exampie of title: Member) <br /> <br />NoNE <br /> <br />License or Permit Number <br /> <br />Questions on this fonnshould be direded tothe Garnbling Control Board at651-639-4000.lf YOlJ use <br />aTTY. you can call the Minnesota Relay Servi~ al1d ask top/ace a call to 651-639-4000. <br /> <br />god <br /> <br />P~^e-(] <br /> <br />dgS:21 SO 10 q".:1 <br /> <br />OvS1-gSl.-ggl. <br /> <br />mopa~s <br />