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<br />Minnesota Lawful Gambling
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<br />LG315R Bingo Hall Personnel Information
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<br />Renewal ADDlication
<br />Altachn1€flt to lG300R ' Bingo Hall UCense Renewal Application
<br />Review information and make necessary manges directly on the application.
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<br />Pot O'Gold
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<br />Binqo Hall Information
<br />Ucense BH013
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<br />Expires on 5/31/2005
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<br />Personnel Information
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<br />Siedow, Goldie Katherine
<br />3873 114th Ln NE, Blaine, MN 55449, MN 00000
<br />Phone (763)783-1840
<br />Current Role: Owner
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<br />55#
<br />DOB
<br />Spouse
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<br />***- **- 4299
<br />06/09/1934
<br />!'iIlN,e....
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<br />'" Criminal H\~n~~a~;~;~tl~~m~~emea. no~II.~1D nu2i~~~ ~~n;fi~~~~ .~~~~~~~~~n
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<br />Da~ged:---1---1_ ,./ Nameofllusl~ '
<br />aty/51ate"Wl1.~e Charges Were Filed .' .- MN Tax ID Number ~
<br />Disposition of the ~
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<br />Organizat[on-lV!embership
<br />LJst all organizatios you beb,g to that<:oodud lawful gambling irl
<br />, Minnesota......'
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<br />Name of Organ1zation -------
<br />Complete Mdresso
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<br />UcenwPermil #:
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<br />_rship Date: ~~_
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<br />Nel',lErnployment --______
<br />ust: all ~oyment you currently hold. ---..
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<br />Employer:
<br />Complere-oMekess:
<br />T~of Business
<br />Date Started: --1--1~
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<br />Position:
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<br />BinQo Hall Personnel Oath and Consent Statement
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<br />1. I have never been convicted of iI felony.
<br />2. I have never been convicted or a oime InVoMng gamblIng.
<br />3. I have never been convlcted of assault, a cimiNI violation invofving the
<br />use of a firearm, or maJdng terroristic d1reats.
<br />4. I am not currently or have never been engaged in or connected with an
<br />megal business.
<br />S. I do not owe $500 or more in delinquent taxes to the state of Minnesota.
<br />6. I have not had a sales and use tax pennlt revOked by the commissioner
<br />of revenue within the last two years.
<br />7. I have filed, alter demand, tax retums required by the commissiOl'lEr of
<br />revenue.
<br />8. I am not a licensed distributor or affiliate of a distributor under Minnesota
<br />St>_
<br />9. I am not a licensed manufadurer or affiliate or a manufacturer under
<br />Minnesota Statute 349.163.
<br />10. I will not be an officer, director, paid employee, or volunteer of any
<br />organization In its conduct of lawful. gambling or represent an organization in
<br />the purchase rt or influence the pun::hase d Ia\"lful gambhng equipment
<br />11. I am not a wholesale: ctlStributor or an affiliate or an employee of a
<br />wholesale: distribUtor of akohollc beverages.
<br />12. I w~1 oat provide any staff to conduct or assist in the conduct of binge or
<br />any other" form of tawfuI gambling on the premises.
<br />13. I wlil not acquire gambling equipment or provide inventory control for
<br />any organization that conducts Iawfu! gambling on the premises..
<br />14. I wnl not prepare or assist in the preparatIOn d any reports require:! by
<br />Minnesota Rule 7B61.CHZO Subp. 3, for an organization conducting lawful
<br />gambling 00 trle premises.
<br />15. I will not provide: accounting services to any organization oondlld:ill9
<br />lawful gambling on,the pre:mlses.
<br />16. I will not soliCit, suggest, encourage, or make expenditures of an
<br />organization's gross receipts from lawful gambling.
<br />17. I witl not ctlarge any fee to a person without whIch the person could not
<br />play bingo or partiCipate in another form of lawful gambllng on the premises.
<br />18. I wiN not provide assistance or partiCipate in the conduct of lawful
<br />gamb6ng on the premises.
<br />19. I will not permit more than 21 bingo oa::asioos to be conducted on the
<br />premises in any w~k.
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<br />BH013
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<br />v.d
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<br />OvBI-EBt.-ESt.
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<br />20. I wit not recruit a person to become a gambling manager or assistant
<br />gambling manager or identify to an organlzatjon a ~ as a candidate to
<br />become a gambling manager or assistant gambling manager.
<br />21. I wdI not be i:mIoIved iolhe ptOCtlrement of, or Inftuencing the precuremeot
<br />of. lawful gambling equipment for an organization wtuch conducts lawful
<br />gambling on the licensee's premises.
<br />22. I will not provide or permit an affiliate or person acting on behalf of the bingo
<br />haD licensee to provide any compensation, gift,. gratuity, premium, contriblltioo,
<br />or thing of value to a Gambling Coob'oI Board employee or member of the
<br />Gambling Control Board.
<br />2J. I will not dIrectly or indirectly give gi1'l:s, trips, prtzes, loans of money,
<br />premiums. or other gratuities to gambling otgaOizatlon, or their employees, other
<br />than nominal gifts not to exceed a value d $25 per organ1zation In a calendar
<br />year.
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<br />In addition, I understand, agree, and hereby irrevocably consellt that suits and
<br />actions relating to the .subject matter or the bingo haD license appllci:ltion, or acts
<br />or omissions arising from such appliGrtloo, may be commenced against me In
<br />any court of competent Jur1SdIctlon In Minnesota by selVice on the Minnesota
<br />secretary of State of any summons, process, 01" plea<ing authorized by the taws
<br />of Minnesota
<br />By signature r$ tt1is document, the undersigned authorizes the Depart:Tne1lt of
<br />Publk: Safety to conduct a background investigatiGa pursuant to Minnesota Rule
<br />7862.0010 Subp. lOa.
<br />By signature of this document. the Undersigned atfinns that Information proVided.
<br />in past applications Is true and {X>ITecl Ganges in application information wiD be
<br />submitted In writing no later than 10 days after the change has taken effect.
<br />Failure to provide required information or providing false or miSleading
<br />Information may result in the denial or revocation of the license.
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<br />Signature, in ink, f bingo hall personnel applicant
<br />Date signed ..LJ SlffJ C2..:>
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<br />Monday, December 06, 2004
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