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LG3010 <br />Minnesota Lawful Gcxmbling <br />Bingol Hall, c,ense Ap lication <br />,P <br />(Seel in�structions for completion of th�is application) <br />Is this application, for a now license, OTa. renew al" ? 0 New 0 Renewal <br />i. Narne of bimgo Ihall <br />Bingo HWI Phone County (where hall is located) <br />KNIGHTS OF CO,L,UMB,US HALL (612)631-2406 EMSEY6.- <br />Strew address lot hall It or Township where hall is located state Zip code <br />,25,55 NORTH SNEL NG AVENUE RIO SEVILLE HN 55113 <br />2. hftift address of dingo l hall city State Zip code <br />A.'-ftne of legal owner of bingo, hall property Pnone <br />NAZARETR. BUILDlI.N,G- ASS-QCIATIONj INC* (rol2)631-2406 <br />I <br />Business Mai'ling Address City State Zip Code <br />2555 NORTH SNELLING AVENUE ItiOSEVILLE MN 55113 <br />S., <br />Names olf all owners, officers, directors, partners, managers and supervisors <br />(each person earned' must fill out a separate Bingo Hall Personnel Information form, L 5 and Affidavit, LG316) <br />tA&I - .54LE!�� Lr5E TAY <br />I--- j Slote proprietorship Partnership X I Corporation 6099777 <br />Wlx� Miftl. � WN <br />, Nw , IN. * I. w• "'. <br />gg <br />T. Havie/dlol any persons listeldin items 4 and 5: Yes No <br />a. been convicted of a if elony? <br />I . ever been oonvIctedof a crime, involving gambling ? <br />m ever, hold a bi'n�gio hall licensel previously in Minnesota? <br />d. owe delinquent taxes iIn excess of $500 as defined in Minnesota, Statutes section 270.72? <br />9. ever, been convicted of assault, cd mi'n al violation involving th el use of a firearm, or making <br />terroristic the re�ats <br />I. after demand,, not filed tax returns required by, the Minnesota, commissioner of Revenue? <br />B., Are any of the Individuals listed in Items 4, or 5, or, a Pierson holdling a, financial or managerial interest <br />lb <br />in the, bingo, hall, or affiliate, thereof — rMl <br />a, licensed distrilbut►r or affiliate of the distributor under section, 349.11 61,? <br />a licensed manufacturer or aff i1i atie of the manufacturer under sectiro n 349.1163 ? <br />an affiliate, of a wholesaile distributor of alcoholic beveraigesio? <br />