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<br /> 1. Name of ding o hall' Phone
<br /> Name
<br /> KNIGHTS OF COLUMBUS HALL
<br /> � �i Slate dip jade
<br /> Address
<br /> 2555 NORTH SNELLING AVENUE
<br /> ROEEVILLE MN �511
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<br /> - + i . .- First Name Ft�l l�[iddfa t�arr�e previous or maiden name Social Secudty•Number
<br /> 2. Last Name .
<br /> *` Wor
<br /> C Slate Zip code Home Phone
<br /> 3. Dome Address �1�r _ I (c/e. ) -i,-�eexi
<br /> N45 Av e, A-5c-L�X.4_r,�:....�. ;.,a�,� ��imhLar sale of issue Date of Birth Birthplace-fir tote Full t�erna�f�p��sa
<br /> «n� ��a. �".es of Service U.S. Citizen Yes No
<br /> Length of residence to Minnesota
<br /> If no,fill In reotstrarlon number: (yews)
<br /> ition wnn nin o hall (check one) 0 Sale Proprietorship � Director � manager
<br /> � L� � �.Your s g
<br /> • ❑ Partner Corp.C#ftcer C3 Supervisor k11
<br /> ISE TAX #_f APELI C. Worlic phone . � r Your duties: Other
<br /> 7. Employment record for past 10 years(include peridds of unemployment or educalion) ,.. � ant
<br /> � address Type ol Business
<br /> �osifa�n Held Dates���r��l��m
<br /> eie,
<br /> ILA— 4 4-0 /0
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<br /> A L) ■�ri F
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<br /> I f�. l r
<br /> s. Place of residence for past 10 years state Zip Mde Dates a1 Residence
<br /> Addnss �
<br /> a
<br /> a
<br /> g. Criminal history statement (except petty misdemeanors). if none,whe ''none.n
<br /> te Charge
<br /> by and Mate �ispositxan
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<br /> se or exem lion#of any 0r . .
<br /> �B. ht ar-�e,address, an� �ioe n p �anization you batong to which conducts la)hquI gambling
<br /> none,write� none.
<br /> . License or Exempton Nurmber
<br /> �aruza�n
<br /> Address Cif stale Zip Code
<br /> cw9unizu�on License ur Exemption Number
<br /> Address City state Zip Code
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<br /> i declare Lh aI Lh;s AP 1r'a tr is wrrecr and wmpleie 10 the best 01 my knowledge and bel+e[.J undersrW iha t
<br /> false and=W'eading answers are jpm aids for denial of ficerrs0 or rairace eon iD1 any fkvnses granted.
<br /> Date
<br /> your 319ra wre ,
<br /> Attach this form to Bingo H61.1 Personnel Aff idivii,LG316
<br /> Mail to: Department of Gam1ng -Gambling Control-Board
<br /> Rosewood plaza South,3rd Floor
<br /> 17 111 _ Counter Road B
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