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<br />Minnesota Lawful Gambling
<br />LG300R Bingo Hall License Renewal Application
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<br />Make changes to information directly on this application
<br />Return Renewai Application By: 3f2/:10P!>
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<br />Bingo Hall Information
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<br />License BH013
<br />Pot O'Gold
<br />3776 Connelly Ave, Arden Hills, MN, 55112
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<br />Phone (651) 631-1724
<br />Fax 11b3-ii3-ii<lO
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<br />Type: Sole Proprietorship
<br />Business 10 1123411
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<br />Current License Expires:
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<br />5/31/2005
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<br />Renewed License Term:
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<br />6/112005 to 5/31/2006
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<br />Persons listed asOwner
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<br />Siedow , Goldie Katherine
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<br />Chief Executive Officer's Oath
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<br />1 declare that this app~cation is correct and complete to the best
<br />of my knowledge and belief. I will familiarize myself with the laws
<br />of the state of Minnesota and rules of the Board governing
<br />gambling and agree, if licensed, to abide by those laws and rules,
<br />including amendments to them.
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<br />1 declare that I am qualified under the terms of Minnesota Rule
<br />7862.0010 10 be licensed as a bingo hall and will abide by the
<br />restrictions set forth in Minnesota 1W1e 7862.0010 Subp. 4.
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<br />I declare that any bingo lease agreements between the bingo hall
<br />licensee and lawful gambling organizalions will specifically identify
<br />any goods or services that the organization is required to
<br />purmase from the lessor or a third party vendor, and that an
<br />goods and services furnished as a part of the lease agreement will
<br />be valued at !:heir fair market value.
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<br />Olanges in the informatiOn submitted in this application wilt be submitted
<br />in writing to the Board and local unit of government no later than 10
<br />days after the change has taken effect.
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<br />S-<>: A;,., l<(lih <"I'"lV\.e~ ,_) 1 <::-~O<.0
<br />Print name of chief executive officer .
<br />c)j,*,).,.~ k~U,u\j~.j;~ LR1;~;
<br />SignabJre, in ink, of~ef executive officer
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<br />Date signed --J--l ~--,. , oS-
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<br />The information requested on this tonn {and any attachments} wiD be used by the Gambling Control Board (Board) to determine your qualiflCatioos to be
<br />involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background irwest:igation of you. You ha....e the right to refuse to
<br />supply the lnforrnatlO"l requested; however, if you refuse to suPply this Information, ttle Board may not be able to detErmine your qualifications and, as a
<br />consequence, may refuse to issue you a r1Cense. If you supply the information requested, the Board win be able to process your application.
<br />Your name and addn:!SS will be public information when receive<! by the Board. All the othes- information that you provide win be prtvate data about you until
<br />the Board Issues your license. When the: Board issues your Ucense, aU of the infonnation that you have provided to the SOard In the process of apply for your
<br />license will bemme publIc. If the Board 00es not issue you a license. all the information you have pro.,;ded in the process of applying for a license remains
<br />prfYate, with the exception of your name and address, which win remain public.
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<br />Private data about you are available only to the fOllOWing: Board members, staff of the Board whose wort assignment requires that they have access to the
<br />information; the Minnesota Deparbnent c( Public safett; \:he Minnesota Altomey General; the MInnesota Commissioners of Administration, Finance, and
<br />Revenue; the Minnesota L.egiSlative AlJditor; national and international 9ambling regulatory agencieS; anyone pursuant to court order, other individuals and
<br />agencies that are speaficalty authorized by state or federal Jaw to have access to the information; individuals and agendes for whkh law or legal order
<br />authOrizes.i!J new use or Sharing of infonnatloo after this notice was gj'l(en; and anyone with your written consent.
<br />Questions on this form should be directed to the Gambling Control Board at 651-63'}..4000, If you use a TTY, call tile Board by uSillg the Minnesota Relay
<br />Service and ask to place a call to 651-639-4000. This publication will be made available in alternative format (Le. large print. Braille) upon request.
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<br />Before issuing or re-aewing a bingo haR IlCe:nse, the Board shall <:ondud or request the director of alcohol and gambling enforcement to conduct a background
<br />irwesl:1gaUon, whictt may Include a review of the applicanfs sources offinandng, ownership, and Ol1Ianization(l1 stJ1lctvre. Actual costs In addition to the initial
<br />and renewal appficatlon fees shall be.bome by the applicant.
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<br />Upon receipt and clearance, your application for renewal wMI be presented to the Gambling Control Boartl for (onsideratloo at a monthly meeting.
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<br />Return license renewal application to: Slate of Mimesota
<br />Gambling COntrol Board
<br />1711 W CO Rd B #300 South
<br />Roseville, MN 55113
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<br />licensina COntact: Roxie Rolph
<br />E-Mail: roxie.roIph@gcb.slate.mn.us
<br />Phone: (651)639-4079
<br />Fax #: (651)639-4073
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<br />Local Govenvnent Acknowledgement:
<br />You must obtain and submit with the renewal application, a resolution of approval from the local unit of government (dty or county)
<br />having juriSdiction over the bingo halt
<br />Bingo Occasions:
<br />CompJete and submit the enclosed LG302-Bingo HaU Occasion list. Rotating Schedules must be provided in a clear legible format (i.e.
<br />calendar) for the entire license period.
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<br />Attachments: 1. LG302 Bingo Hall Oa:asioo List, 2. lG315R Bingo Hall Per"sonnellnformaoon, 3. Local unit of govemement approval
<br />resolution (dtyor county), and 4. Oleck for $4,000 license fee payable to "State of Minnesotan_
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