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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 -01878 001 EFFECTIVE DATE:04 /01/96 <br />EXPIRATION DATE: 03/31/98 <br />ORGANIZATION INFORMATION <br />NAME OF ORGANIZATION: Lions St Paul North Ramsey 500th Club <br />CEO NAME: Raymond Hanson <br />C';'a 'f% <br />Ireneaus William Massman <br />365 Koehler Rd <br />Vadnais Heights MN 55127 <br />DAYTIME PHONE NUMBER: 612 - 426 -0702 <br />MEMBER SINCE: 10/06/77 <br />GAMBLING MANAGER INFORMATION <br />DATE OF BIRTH: 01/23/27 <br />SEX: M <br />SOCIAL SECURITY NUMBER: 469 -30 -5260 <br />EDUCATION INFORMATION <br />MOST RECENT CONTINUING EDUCATION CLASS YOU ATTENDED: 12/04/96 <br />BOND INFORMATION <br />BOND COMPANY NAME: Cap Fidelity BOND NUMBER: CC555072 <br />GAMBLING MANAGER CHANGE <br />When your organisation 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 />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 />Note: A New gambling manager may not assume duties until he /she has received the gambling manager's license from the <br />Gambling Control Board. <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 />Not - ed Signature of CEO <br />Date <br />11-7 -97 <br />Notary Public Information. Notary Public Seal <br />must be current and correct; seal may not be altered. <br />Subscribed an <br />day of <br />worn to before me this 7 <br />at <br />,\ AAI \A,'AA, ■A,..lr \MAAAAF "AA AAAA • <br />Notary P111fi' KATHLEEN A. GLANZER <br />�, RAMSEY COUNTY ( ontinued on Back) <br />My Comm. Explraa Jan. 31, 2000 <br />Page 120 <br />NOTARY PNOLJC MtNNCSOTA <br />