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East <br />LG212GMRPRINTED: 10/13/97 <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 -04219 002 EFFECTIVE DATE:05 /01/97 <br />EXPIRATION DATE: 03/31/98 <br />ORGANIZATION INFORMATION <br />NAME OF ORGANIZATION: Canadian Days Little Canada <br />CEO NAME: Raymond Hanson <br />Mary Ann Mildred Auge O'Kane <br />90 LaBore Ave <br />Little Canada MN 55117 <br />DAYTIME PHONE NUMBER: 612- 484 -5904 <br />MEMBER SINCE: 07/01/77 <br />GAMBLING MANAGER INFORMATION <br />DATE OF BIRTH: 05/22/35 <br />SEX: F <br />SOCIAL SECURITY NUMBER: 477 -32 -6871 <br />EDUCATION INFORMATION <br />MOST RECENT CONTINUING EDUCATION CLASS YOU ATTENDED: iff r /0 4, <br />BOND INFORMATION <br />BOND COMPANY NAME: United Fire & Casual BOND NUMBER: 5188896 <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 <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 />assume duties 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 />SIGNATURE OF CHIEF EXECUTIVE OFFICER (CEO) <br />r <br />Not <br />Date <br />ed Signature of CEO <br />/�- 7— 97 <br />Notary Public Information. Notary Public Seal <br />must be current and correct; seal may not be altered. <br />• ,nAA,.,,,,,,Ar AA, \n,\t,f AAAAAA <br />KATHLEEN A. 4ffiget„, <br />NOTARY PUBL C- (NNES6TA <br />Subscribed an <br />day of <br />m to before me this <br />A19 9i <br />diAle <br />Page 114 <br />IC <br />(Continued on Back) <br />