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Minnesota Lawful Gambling LG300 - Bingo Hall License Application (Fee $2500) A bingo hall license is required for any premises where more than one organization conducts bingo. Binao Hall Information Page 1 of 2 3/00 Fee � h e c kl Name of Bingo Hall DBA, if applicable _Capitol City Investments' LLP Roseville Bingo Hall Street Address of Bingo Hall c�cy, State or Province, Postal Code 2525 Snelling Avenue Roseville, MN 55113 �N r �� Fax Number � �-`Y'�'g-3184 (temporarily) _ (612 � %81-3670 _ MailingAddress(ifdifferentfromabove) City. State or Province, Postal Code 3647 McKinley Street NE Minneapolis, MN 55418 Of BUS111eSS (check one box u Sole Proprietorship � Corporation V Partnership Limited Liability Co. Minnesota Tax Identification Number (if none, write "None"): _ Owner(sl Information LI Firm X Limited Liability 87 � The owner of the premises must be the lessor of the bingo hall. �l Subleases arenotallowed. � Attach a LG315 - Bingo Hall Personnel Information form for each person listed in this section. Name of Legal Owner of Bingo Hau Property Capitol City lnvestments LLP Phone (�51) 699-6656 Business Mailing Address CitylStatelZip 246 So. Albert Street St. Paul, MN 55105 Names of all owners, officers, partners, directors, managers, supervisors, and persons or entities with a direct or indirect financial interest of five qercent or more in the aq�licant: Name Title II Name Title 1. $2 e attached sheet entitled Z. "Ownership" s. The IflfOrti�8ti0n requested on this fotm (and any attachments) will be used by the Gambling Control Board (Board) to determine your quali- fications to be involved in lawful gambling activities in Minnesota, and to assistthe Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to Issue you a license. If you supply the i�ortnation requested, the Board will be able to process your application. Your name and address will be public information when received by the Board. All the other information ihlt you provide will be private data about j�DU until the Board issues your license. When the Board issues your license, all of the jnfpftTlBtip� that you have provided to the Boerd in the pfoC65s of applying for your license will bg�7g public. H the Board does not issue you a license, all the Information you have provided in the process of applying for a license rem ains private, with the exception of your name and address which will remain public. 10 I� �� I. I, � Private data about you are available only to the following: Board members, staff of the Boerd whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attomey General: the Minnesota Commissioners of Adminis- tration, Finance, and Revenue; the Minnesota Legislative Auditor, na- tional and international gambling regulatory agencies; anyone pursuant to court order: other individuals and agencies that B�g specifically authorized by state Of federal law to have 8CC2SS to the Information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notiCe was given; and anyone with your written consent. Questions on this twm should be directed to the Gambling Control Board at 651-639-4000, Hearing impaired individuals using a TTYmay Call the Minnesota Relay Service at1-600-627-3529 and ask to place a callto 651- 6394000. This publimtii will be made available in atternetive format (i.e. large print, Braille) upon request.