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<br /> Iffinnes o t a Lawful ling
<br /> Bingo all Personned _ 4y
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<br /> Phone
<br /> 1. Marne of bingo halt 2 )631-053 8
<br /> KNIGHTS OF Stale ZIP code
<br /> Address �'
<br /> R S E I LLE NON. 5 511�1
<br /> 2555 11 '� SILLII A �.■�, i
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<br /> 2. Last Marne Fxrs1ame
<br /> Full huddle flame Previous or maiden name Serial secuery. urnber
<br /> Je vo-od
<br /> ddres s City State Zip code dome
<br /> 3. borne
<br /> % - R # ` i
<br /> s e�lUmber Mate•01 ! spa a Date of Binh Bi�p1ace-C�► # State Full Name�� pause ,
<br /> A«Ρ Drri ve(s V cen
<br /> Dates of Sere Citizen des No Length of residence in Minnesota
<br /> 5. Br 1 .�,�..
<br /> } If no fill in recIslration nu ears) 1Z
<br /> .. bingo hall check one ❑ Sole Proprietorship ❑ Director Manager
<br /> ;� LE � 6.Your s�y�n with � � �
<br /> 0 partner Corp.O1'#lcer 0 Supervisor
<br /> JSE TAX - Other
<br /> PLIC,• rk phane(.., Your dupes:
<br /> 7. Em lto yment record for past 10 years (include periods of unemployment or education) 1� ent
<br /> p Address Type of Business pass on meld Dates ai Er►p yrn
<br /> Em' Yer
<br /> ti
<br /> . p1pce of residence for past 10 gears Z code Dates of Residence
<br /> Addms s City State - R
<br /> /7ej 0 + j 77 .
<br /> uu
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<br /> 9. Criminal history statement (except petty misdemeanors). if acne,write"none."
<br /> _ hat a City and State USDO M
<br /> ' e 'a of an or anization you belong to which conducts lawful gambling.
<br /> 10.Name,address, and license or exam i n �
<br /> K none,wrhe "none! •
<br /> License or Exempfan Number
<br /> Address Ci by state zip e ,
<br /> ■
<br /> License or E xe mp6an Number
<br /> oreanixizn
<br /> Address ctl' State zip Cie
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<br /> I declare 1hal this fa t»is=rreci and complete ra the boa at my k ledge b efiet.t understand tha r
<br /> false a n d rntsle�ng answers are V=nds for dWal of f cease or re ro m eon o1 any lker s es gra n red.
<br /> your siq awre Date
<br /> Attach this form to Bingo Ha11 Personnel AfSidavR,L 31 E
<br /> Mail to: Department of Gaming -GamblIng Contra! ]Board
<br /> 2#1P'�",�fir, ��,���4,�rr�,�^�r�� �,�%�mtam� ia,
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