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<br /> 2555 NORTH
<br /> KNELLING AVENGE ROSEVILLE IAN 55113
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<br /> -3ALE & 6,Your shion with bingo nail (CMCK one) tj Doge Proprietorship Director I Manager
<br /> r ❑ F G-rI ner ❑ Corp.Wicer ❑ Supervisor
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<br /> aeK bane ) - ,� Your duties: ❑ Other
<br /> 'f APPLICII,7. Employment record for past 10 years(include periods of unemployment or education
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<br /> Add rI City, State Zip and a Dales of peside nce
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<br /> g. Criminral history slaiernent(except petty MiSde.meanors). none,wrhe "none.
<br /> Charge City and State D;sposi i
<br /> and license �r exerrr tion at an or anmation you belong to which oonducts iawiul gambling. .
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<br /> I dedare that this app m6on is correc.t and c mplete to die best of my Mcwledge wr d beFel.!undefstand that
<br /> false a�pidr misfea dreg are wLsrs are gmcnds for dears)of ftense or rev=don of any licenses pmnled.
<br /> Your si -' ..,rep date
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<br /> Attach this form to Bingo Hati1 Personnel A#tida'v"I L 316
<br /> Mail to: Department of Gaming - Gambling Control Boy.:'d
<br /> Rose%good Pizza South,3rd Floor
<br /> 171011 W. County Road B
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