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(Rev.VWv90) JJ111go J. J. r e r o Illy. il. jLj U.L 1jJL CL L 1%J A-A <br /> ------------ <br /> .f.L '� ;�?.'�; •�{ '`+ �}.r.�r� X11 ' <br /> "ir� <br /> ±{ <br /> � �,'�.7r r' :irr� L r,a •� }r ?}r �' ti ti r <br /> Phone <br /> il 1. Name of Ungo hal <br /> ��' COLUMBUS HAIL (6 12. )6 3 1--0 5 3 8 <br /> NIGHTS Zip code <br /> }address city - state . <br /> 5 5 NORTH NELLING AVENUE � <br /> ti <br /> di y <br /> L <br /> �r 3d � ��-y-1�+� � � F Orr. ..} •� {{�� ��••� <br /> Fir t Name Full M1iddle Herne Previous or" alden name <br /> �. Last plill <br /> P,k Tor Wnr- Y�(t 1 <br /> 3, Home Address city► State• Zip wde Home Phone <br /> �kj' .5 M tilill log ' -*'I� !ocw�l 91 <br /> . , 7 �� <br /> A n�«riples License Number Stale o1 issue D!31* r%f'Pl;r1}� Bi�hplace- State Full Berne of �use <br /> M t'a <br /> Sates of Service U :mizen., 'f as,m No Length of residence in Minnesota <br /> fit•n'L in registration number: ears <br /> 6.ALE & Your position with bingo hail (check one) 0 Sole.Proprietorship I ' Director � � Manager <br /> • Q 2�Corp. aper�r�sor <br /> .PaAnk'.:�l Officer <br /> TA ,.ti <br /> r wok hole Your dUti, S.. - 'l'hef <br /> .9 P L I C ( -+ a Jr <br /> t record S6r past I earn include eriods•o!un Mployrnent or education) <br /> EpIoymen ' { <br /> Ern ' er Address - Type cf Business• Pcstt�`on'Held Dates as E iployment.. <br /> �Y <br /> i - � <br /> .T P'7, � � - <br /> I e r + <br /> ` 1 r- -Q. � 9 <br /> 8. Flece of residence for past 10 years <br /> • tats Zip code Dates of Wdence <br /> 4 Address My <br /> VIVP 6A L/7 <br /> a <br /> • <br /> 9. criminal history statement (except petty rnisdernean0'rs).-1f none,write "none." � <br /> ate are City and Stale �ispsitn .......... <br /> Will <br /> io.Name,address, and licensa or exemption-of any organization you belong to which conducts lawful gambling. <br /> ti none,wr a Arnone.'' 0� ' <br /> • License or Exemption�luml. <br /> orgx <br /> m <br /> - U, <br /> Address pity - State Zip code <br /> 4 <br /> + lidl <br /> o a f License or Exernpidon Nurnll, <br /> city- Zip Code <br /> Address - - <br /> ,� 44I Lti�: ■Y <br /> a r } +r'-; <br /> {r r •�ti � r r .. <br /> !dedare jhaI jh+s.2pP1ica6n k cofrecl and coi*leie 1a the bev of my krx*1edge w d belief.J understand that <br /> false andmisleading Hers are grac+nds lour d al of Eevnse w#eye eon crany lkvnses pr2nIL d, <br /> Your 4-lire - oats <br /> OL <br /> Attach this 16rM)&.M'�j 6'Hi1j Personnel Atfldavlt, LG31 S a •. <br /> ail, Mail lo: Departmenttiof• arnIng -Garnbiling Control'hoard <br /> Rosewood T!1a7.a South,3rd Floor <br />