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East <br />LG212GMRPRINTED: 02/11/99 <br />STATE OF MINNESOTA <br />GAMBLING CONTROL BOARD <br />GAMBLING MANAGER LICENSE RENEWAL APPLICATION <br />FOR BOARD USE ONLY <br />AMT. PAID <br />CHECK # <br />DATE <br />INITIALS <br />Incomplete, false, or misleading application information may result in denial of a license. <br />LICENSE NUMBER: G -00864 002 EFFECTIVE DATE:08 /01/97 EXPIRATION DATE: 07/31/99 <br />ORGANIZATION INFORMATION <br />NAME OF ORGANIZATION:ce Little Canada Vol Dept( Fire Dept . <br />CEO NAME: Richard Boss III <br />GAMBLING MANAGER INFORMATION <br />Robert Gordon Johnson <br />2815flIcestdietc 2442 North Rice St. <br />Little Canada MN 55117 <br />DAYTIME PHONE NUMBER: 612 - 484 -2722 <br />MEMBER SINCE: 01/15/77 <br />DATE OF BIRTH: 02/28/43 <br />#1 7 8 SEX: M <br />SOCIAL SECURITY NUMBER: 475-46 -9005 <br />EDUCATION INFORMATION <br />MOST RECENT CONTINUING EDUCATION CLASS YOU ATTENDED: 11/20/98 <br />BOND INFORMATION <br />BOND COMPANY NAME: State Surety Co BOND NUMBER: RPS325624 <br />GAMBLING MANAGER CHANGE <br />When your organization is using this renewal application to change its gambling manager, complete one of the following sections: <br />Emergency Change - Allow up to five working <br />days for processing <br />The chief executive officer, by signing below, <br />affirms that the emergency application is due <br />to the following reason (Check one and fill in date): <br />Death of gambling manager on / <br />Disability of gambling manager on <br />Termination of employment of gambling <br />manager on / / <br />Note: A New gambling manager may not assume du <br />Gambling Control Board. <br />Other Change - Allow up to ten weeks for processing <br />The new gambling manager's license should become <br />effective (check one): <br />The day after the current gambling manager's license expires <br />(for example, if the current gambling manager's license expires <br />07/31/97 the new gambling manager's license becomes <br />effective on 08/01/97, provided that all application information <br />is complete). <br />_ When the application has been processed by the Gambling <br />Control Board- -the effective date will be the first day of <br />the month. <br />es until he /she has received the gambling manager's license from the <br />The current chief executive officer of your organization must sign this application in the presence of a notary <br />SIGNA <br />F EXECUTIVE OFFICER (CEO) <br />Notari <br />Date <br />d Signature of CEO <br />05/18/99 <br />'.I!LUA4' 1 ;A1 - <br />rt,teo <br />Notary Public Information. Notary Public Seal <br />must be current and correct; seal may not be altered. <br />Subscribed and sworn to before me this 18 th <br />day of May ,1999 . <br />`t �Q g <br />Notary Public <br />Page 153 <br />(Continued on Back) <br />