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ST TE'OF MI.? NNES0 TtA FOR BOARD USE ONLY <br />Evol, GAWLING CONTROL B'011 ,RD AM'T. PA I D .......... . . ........... <br />GAMBLINGUAM GE'R LICENSERENE WA L A PPLIGA TION' CHF-I(11",K <br />DATE <br />LG2,12GM,RP'RINTEDI: 09/08/97 IN'ITIA,LS ............................................. <br />. .... ... . . <br />Incomplete, falseq, or misleading application Information may result In denial of a Ircense. <br />LI'CENS�E, NUMBER.- -00111 OI 4 EFFECTIVE DA,TE:10/1011/96 EXPIRATION DATE: 02128/98 <br />ORGANIZATION INFORAIATION <br />NAME OF' O�RGAINIZAT'I'ON-.1 American Legll,oln Post 5412 Roseville <br />CE0 NAME: M�villid', Hagg, <br />GAMBLING MANAGiER INFORMATION <br />Kenndh Roy Edabu�rn DATE % <br />1057 Bellecrest IDr, <br />Maplewood MN 55109 SOCIAL SECURITY <br />DAYTIME P'' OIN NUMBER. 612-736-7764 <br />MEMBER SINCE: 061/011/%, <br />EDUCATION 'INFO,RMATION <br />MOSTRECENT CONTINUING EDUCATION CLASS YOU ATTENDED,. 081/119/97 <br />BOND INFORMATION <br />I <br />COMPANY NAME.- Commercial Unioln Ins BOND NUMBER., <br />GAMBLING MANAGER CHANGE <br />When Your organizationis using, this renewal application to change its gasnbling manager, complete one of the following s,ectionis-. <br />ii <br />Emenency Chanlgle - Allow up, to, five working <br />days for pr=ssing <br />The chief executive officer,, by signing below, <br />4, <br />affi ms that the emergency ap ication is due <br />41 <br />to the following reason (Choi one and fill in dateI): <br />Death of gambling, manager on, <br />Delsabillity of gambling manager on <br />Termination of employment of gamblifig <br />manIagier on <br />Other, Change - Allow up to ten weeks for processing <br />The new gwnbling manager's, license should blecom,e <br />effectivie (cheilck one).- <br />bi <br />Note: A New gambling manager, may, not assume duties until bielsh,e has received the gamblitig, manager's license froni the <br />Gambiling, Contr�oll Bolud,. <br />11he cun=1 chief executive officer oif'you,r organization must, sign this application in the p,res�ence of a notary <br />S A, ki- ER (CEO) Notary Public Information. Notary Public Seal <br />,IGN �-,"E OF' CHIEF EXEC Vw 0 <br />sea] may not be altered., <br />must be current and correct <br />12 <br />Notariwd Signature of CEO <br />Subscribled and swom to before me this A-mi <br />hy of J9 <br />(Continued on Back) <br />