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FOR OFFICE USE ONLY <br /> Fee <br /> Dale <br /> Chk lnWal <br /> L 300 <br /> Minnesota Lawful OvambHng Bingo H License <br /> Application - Part 1 <br /> (See instructions for completion of this application) <br /> Is this application for a new ticease, or a renewal? O'New 21 Renewal <br /> 1. Name of bingo half- Bingo Hall Phone County(where hall is located) . <br /> KNIGHTS OF COLUMBUS HALL (612 ) 631-0538 RAMS EY <br /> Street address of hall City or Township where hall is located State Zip code <br /> 2555 NORTH SNELLING AVENUE ROSEVILLE MN 55113 <br /> 2. Mailing address of bingo hall. City State dip rode <br /> 2555 NORTH SNELLING AVENUE ROSEVILLE MN 55113 <br /> 3. Is the bingo hall located within city limits? Yes No If}hlc,'indicate township in which bingo hall is looted <br /> � ��:-'r:;-'•}S�r`•'r�:�}.��.•;'� J *~��'''�F��i.�. - = �� R..• Sy�---': ,. ,i '�• :� ti• :•i�Lrr k <br /> r `,.�.:�+ ,�� 7a#i'f,�-i■.�::��� � r •if •�•��•, ,ti���r � { � �tisr'.-. �;� ti f} �.} r •i�' r <br /> .�- .�sy'�-. •-.� :err -ter.• �:T��•. . �• •��:r� Y. -•:•��.�• :ti•. s. <br /> 4. Name of legal owner of bingo hall property have <br /> BUILDING ASSOCIATION ITC a 61�2) '631-0538 <br /> NAZARETH $ r <br /> Business Mailing Address 3tats Zip Code <br /> 9-S-55 NQRTH STJRtLING AVENUE ROSEVILLE MN <br /> 5. Names of all owners,officers,directors,partners, managers and supervisors <br /> (each person named must fill out a separate Bingo lull Personnel Information form, LG315 and Affidavit, L 316) <br /> a. E <br /> JOHN F I T Z S IMMON S f`• ARM.AND G. ORFE I k. <br /> b, 9� l„ <br /> WILLIAM FR RMUTH ROBERT F. ROSENTHAL <br /> o` <br /> ROBERT t RITTA h' M. <br /> d. ROBERT Me MARCO r SR* <br /> r. <br /> e. 0 PAUL H, MILES �' . <br /> r:�'':•�'.{•rr7r r{7rti--ti�$:�t'r:'� ktir•7}�'ti:..}# .''. ��� X-}: � TAY F <br /> 6. Iwo� . 5.A-.-e E <br /> 7:3 Sole proprietorship Par#n ersh ip 0orpo ration 6099777 <br /> -.•}V:Nk' s •:• ':•.d.'3'f r:{rs fi •J. .$+ : j �.• .'.t l} �} .:.r• .�'i k.' <br /> 7. lave/do any persons listed in items 4 and 5: Yes No <br /> been convicted of a felon �. <br /> a.� n co n tot ?Y <br /> b. ever been convicted of a prime involving gambling? <br /> ever held a bingo o hall license rise reviousl in Minnesota? <br /> C, h i � previously <br /> excess of 500 as defined in Minnesota Statutes section 278.72? <br /> ��awe delinquent taxes�n � . <br /> e, ever been convicted of assault, criminal violation'involving the use of a firearm,or mal i ng <br /> er <br /> t r ristic threats? <br /> tax returns required a �] <br /> f. after demand,not filed � Y the Minnesota Commissioner of Revenue? <br /> 3. Are any of the individuals listed in hems 4 or 5, or a person holding a financial or managerial interest <br /> in the hi ngo ball,or of f illate thereof__ <br /> $licensed distributor or affillate of the distributor under section 349.1619 <br /> ' er or aff iltiate of tha rnanu#acturer under section 349.1 E3? <br /> a licensed manuf actu r <br /> A 4 A k i it -r r% ev%1%r%t imi-ka og a Q 9 F7 <br />