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i 1 yL�+i�`1•rrrj 1��Y��� .. <br /> L 1 Personnel Infor ton <br /> �+ ��'*�'r�'Q'a`.ti'•'`•`.?�"+�',:'#u'� :may'`•ti�"{'�'.�'�.�:}{:'�r".•v''��'� {',���~3??.r+':•:�?�`,�.}L�rrf':�'•'�:}` r'}" <br /> rr�,+.ti� �trti{! � r•t :ti�'',�-,'TTr . ..ti.,r y�r �rRti_r,':L7-`:�{' �ti�"ti'r:�; .,�y t. ti�•:}}CJ•#•{ti}!w� <br /> yya,�k +.`fib'; • ,+}��•`v�fr..•.r �• 'i y L!*{'� �}"•. y'-•{•. �:�::.s}'_�rtiti-�•.��F .ti�:}. {J+rri-:.�-y:•• .�• .r.-. .y <br /> N 4�• �+�_,..g�S• L *S�ti .{ ti L.4•� s •�. '{�y•.� �••i�'l }."':•{' } .ti {�; .S r- .Y.•.•: f.{•}••:; Y <br /> ,Y'{� � v •�ti .r�:i',Sti � ��-�••.��+r+ti;}. �. :y�•a�.tir:�rr•�r'' Hsu-�:: r:��•,r�• •� {�',}s{�ti•Lq.�;•ti:. a ti.:a ssLtir�'air:•r�.�'.{�i�'� #�� <br /> �Y {:. .r•' `} � y_. ti;'{•; Y{ Y'•�: ti'. S'v .���{h'• tir. �' ••�-':�.' ti;•••rr. � r� •.?� <br /> } •.r`' •�••r`''��[+t+•ti� r '*{• ti•. �a*r ,t+ }'r.r. �-'4"{:• .;{�.•: �:•rd•.s.�{{•�:•}:�� {!'ti�'r ''L- <br /> r •aU10�' r+'+"•~S' y;`.s' r+ti } K{ �} :}' •''fr`�.r!�:.+N}}}:'�:?s}}`r:.-ti'rr}':ti {r� yY. ti •}�r'uvr'r}ti,. <br /> .fig <br /> Phone <br /> 1. Name of bingo hall <br /> ��� � <br /> 631-0538 <br /> I G HT S O ��LLI �U� HALL city state Zip Cede <br /> Address - <br /> 2555 1NORTH NELLING AVENUE TILLB <br /> MN 5 5 1 1( <br /> r .L"}4`r, -.}tia- '•} !•�S Im <br /> a e Previous or m pide n name social cunty•Number <br /> rn <br /> "r ICU ATV <br /> 2. Last Name First Mae F u l l Middle]� rn <br /> ZLI!L-�rl r f <br /> Stale ZF",de Home'phone <br /> hone <br /> 3. dame Address t�.,. r <br /> iM <br /> ` s e dumber Mate of Issue Date of Binh Bi tf1 aoe-C Full Name of spouse <br /> 4. Drivers ticen <br /> r Length of residence in i linne sots <br /> 5. Branch Of M1111 Y%% r�ri� Dates of race ._� �.�.�it��er� Yes � �o g MW I <br /> If no fill try realstretien cumber: eats �..� <br /> .� position whh bingo hall (check one) Sole Proprietorship � Director aneger <br /> AI�� � B.��ur s � <br /> � partner ' Corp. dicer Supervisor <br /> JSR TAB 'Other <br /> OeA phone( Your duties: 0 APPLIC <br /> m to rnent record io r past 1 ears(includ a periods of unemployment or education) <br /> 7. p Y <br /> m ' er Address YYRe of Business l�oslr�on Reid Dates a',Enpl��ment <br /> E r�Y <br /> . OF I ML <br /> . Place of residence for past 10 gears Zip code Dates ct Residtnce <br /> Adokoss City State <br /> g. Criminal hislory slsternent (except petty misdemeanors). It none wrhe `none." <br /> pea: ph a City and Smi a Di s;>o.Oon <br /> r f r• <br /> Jf f• r IIW <br /> T <br /> address and dice n s e ore a rnptio n of any o rg a nnation you belong to which conducts lawlui gambling. <br /> 10.Name, � , <br /> U nonei wale "none.s <br /> License e;Exernpton Number <br /> Address City State zip code ' <br /> License or E xe apron Number <br /> Address City State zip Code <br /> •a}�r rnsa.L 1+, Sati►L tiyty.y.'r•.1�'R��w••sY?��:'W' �;-'::�. <br /> aaa■ � ?; '� .��:?• }'�}� tilt_fr-titi : r'. S+::r: 4 'r,-}L •.ti}{*.;'�� <br /> r}ti �.`} � �;.�� 4'�r'?.t�y r;}='":ti:. _f rr.• '`7v:-;;sti ti Y:e'• y�,s' •LY f. <br /> ' ? ti"`irs ~� b ■w}i•a}y'{}fr}J"fir :.? f. a ~};ti}rr.} tititi}.. rrry: { �r}ti -.s. T s'-} } 3 '.ti{ :�-:-• 'r,. {{ �;;r <br /> -�r r' yes'.. {{.�*• 'r r r. {;. } r .�r;L' ti L:ti- tire"'.y~• { r ..•r <br /> _ �• ••`!�}tiyr�1 '�;�,.�y-r�-{•7 },ti�.•,,�{;� ti'�Lr::• -�. {�G{'�:�:'.�.}rr'••ti{- �{ rY. s•� i�'r��'��• ?, � �''.••�'f rL�.}}',.;i�. ;7tir{�:; �r••.r.{•'• .hv'�{•'�• r��}}rh•..y....... <br /> it •{41:' y+t$ti r .1{;:s9;:K.:d{ }.�:s-.ti rl{;:7f',�jti:'.+�•-'•:v:•r:.!:.... :=?:•'r{"r-''-ti�''r r rr:-'�•. _ .�:.:rti' ' - <br /> L '{.J.Y.r •r. <br /> I dredare iha t Lhi rtce is=ffecf and c mp!ete lo the best of my knowledge and belief.I undeesiand ftt <br /> used misleading Hers aregivinds l dens!cf icense or revooadon of any Incenses grafi1ed. <br /> Cate <br /> your siorarure <br /> d�13.� <br /> ■ <br /> Aach oMali Personnel Affida01, LG316 <br /> this form to Bingo . <br /> Mail to: Department of Gaming - Gambling Control $oa.rd <br /> Rosewood Plena South,3rd Floor <br /> �' �3 W rIn-1.1j P n�z ri R <br />