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intr o to Lawful � ng <br /> (Rev.I L��I ti a personnel Information <br /> � r '�.iR�l..r'."" �r � ~ t{+ •��{~ r k.Y�-k ��`}'.�-r•�.}r .�}• •.n��r.r.r ,ti :f'?�••r�.r`,�,}•.��.:}' .r. <br /> hone <br /> dams 0 1 ' <br /> 74 i <br /> r <br /> r%Code <br /> Address <br /> cif Mate ' <br /> - Ir? <br /> Y �F <br /> .l:� }`�.�.+ • '�r�r'7r• ;vi.'? ::� .'l'..ti j...'r. �• •'k 1 •r` <br /> . ... re ious cr rrra; en name Social cudry Nurnbe <br /> . LasL Name First Mama Full h��ddte Narne <br /> /& :Z <br /> * dome Address city State zip a Home Phone <br /> �w. <br /> � 6" ( <br /> � State Full Name of pose <br /> 44. Ddve(s License ber Mate of fssUe Date of Birth Bi�piace- <br /> .� ` <br /> ' r s /e-A. <br /> �. Brash of f+�i�tt Service Da es of Service U.S.Citizen Yes NO Length of residence in�ltirtnesot <br /> - If no fill in registration number: ears <br /> .Your posKiOn with bingo halt (cnecK one) k.j oole Proprietorship EQ Director Manager <br /> -�--i r5 partner C1 Corp.dicer 0 Supervisor <br /> we honed Your duties - Other <br /> p _ <br /> 7. Employment record for past I D years(include periods of unemployment or education} <br /> Emp'oyer Address Type of Business Po sliJon Held Dates of Employmef <br /> / - - Q 2 � J <br /> F - 4", <br /> It * { t f --sF <br /> ■ <br /> 'S A <br /> .r ry J. FJ/i S. <br /> .! r7/ <br /> . place of residence for past 10 years <br /> Address <br /> State dip code Dates-of Resider*ce <br /> Addr - <br /> I, <br /> Criminal history statement (except petty misdemeanors). if n6ne,write "none." <br /> Dais Charge city and State Disposif n <br /> .VIII <br /> III <br /> iv <br /> IN <br /> MII <br /> Name,address and license or exemption#of any organization you belong to which conducts lawful gamblingi . <br /> N none,write"none. . <br /> I <br /> Organizakn Ucense or 1Exemp6on Nu' <br /> dY <br /> Address ctrl State Zip cue <br /> MIII <br /> Y Gtr <br /> oroanin n License or Exempd n Nurl- <br /> Addre city State Zip Code <br /> t . <br /> .r, <br /> i declare that th;s appfhcatbn is correcx and complete Jo the bw of my knaMedge and beret.I understand that <br /> u, false and misleading angers are grounds for denial of fcense or revocason of any licenses granted. <br /> Your si .shire date {� <br /> mup r <br /> Attach this form io Bingo Halt personnel Af#idavit, L 31 B <br /> Mail lo: Department of Gaming - Gambling Control Board <br /> Rosewood Plaza South,3rd Roor <br />