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Minnesota Lawful Gambling Bingo Hall License Renewal Application - LG300 Fee Check # Bingo Hall Information License Number: BH046 Name of binao hall: DBA, if applicable: Street address (aty, state or province, postal code): Phone number (with area code): Mailing address (ft different than above): Effective Date: 2 /1/2001 Little Canada Market Place Expiration Date: 1/31/2002 2900 N Rice St Little Canada, MN 55113 (651) 483 -1203 Fax number (with area code): Type of Business (sole proprietorship, partnership, corporation, limited liability co., firm): Limited Liability Company Minnesota Tax Identification Number: N/A Local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application: On behalf of the city, I acknowledge that this application will be forwarded to the appropriate city officials, the city must pass a resolution specifically approving or denying this application, and.a copy of the resolution will be forwarded to the applying organization. Name of city: Little Canada (Signature of dty personnel receiving application) f<"� Title Date // / 2U/ CO If the gambling premises is located in a township, both the county and township must sign this application: For the township: On behalf of the township, I acknowledge, by this signature, awareness of this application and that the township has no authority to deny or approve an application. Name of township: (Signature of township official acknowledging application) Tide Date / / For the county: On behalf of the county, I acknowledge that this application will be forwarded to the appropriate county officials, the county must pass a resolution specifically approving or denying this application, and a ccpy of the resolution will be forwarded to the applying organization. Name of county: (Signature of county personnel receiving application) Title Date_/_/__, Questions on this form should be directed to the Gambling Control Board at 651- 639 -4000. Hearing impaired individuals using a TT' may call the Minnesota Relay Service at 1-800-627-3529 and ask to place a call to 651-639-4000. This publication wdl be made available in altemadve format (i.e. large print, Bilge) upon request. The information requested an this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved In lawful gambling actinides in Minnesota, and to assist the Board In conducing a background Investigation of you. You have the right to refuse to supply the information requested; however, 1 you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse t0 issue you a license. If you supply the information requested, the Board will be able to process your application, Your name and address WO be public information when rerei' by the Board. 4:1 the other information that you provide will be pnvate data about you unitl the Board issues your license. When the Board issues your License, all of the information that you have provided t0 the Board In the process of applying furyour license wdi become public. if the Board does not issue you a license, all the information you have provided in the process of applying for a license remains pnvate, with the exception of your name and address which will remain public Private data about you are available only to the following: Beard members, staff of the Board 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 Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant co court order, other individuals and agencies that are specifically authorized by state or federal law to have arrnss 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 Page 5