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License No. <br />Date: <br />CITY OF LITTLE CANADA <br />APPLICATION FOR BINGO LICENSE <br />Yearly License Fee: $ Approved by: <br />(Expires Dec. 31, 19 ) Building <br />Fire <br />Police <br />I, <br />Application shall be submitted at least <br />30 days prior to the bingo occasion <br />AND I, <br />Name of Authorized Officer of Organization Name of Designated Bingo Manager <br />Hereby submit in duplicate this application for a license to conduct the game of bingo <br />in accordance with the provisions of the City of Little Canada Ordinance No. 200 and <br />Minnesota Statutes Chapter 349 for the license year ending <br />Signatures: <br />Authorized Officer of Organization Designated Bingo Manager of Organization <br />A. The following is to be completed by the duly authorized officer of the organization: <br />1. True Name: <br />(last) <br />2. Residence Address: <br />(first) (middle) <br />(street) (city) (state) (zipcode) <br />3. Date of Birth 4. Place of Birth <br />(mo.) (day) (year) (city) (state) <br />5. Have you ever been convicted of any crime other than a traffic offense? <br />Yes NO . If yes, explain <br />B. The following is to be completed by the designated bingo manager of organization: <br />1. True Name: <br />(last) <br />2. Residence Address: <br />(first) (middle) <br />(street) (city) <br />(state) (zipcode) <br />3. Date of Birth 4. Place of Birth <br />(mo. (day) (year) <br />(city) (state) <br />5. Have you ever been convicted of any crime other than a traffic offense? <br />Yes No . If yes, explain <br />6. How long have you been a member of the organization? <br />7. Attach a copy of the official resolution or official action designating you <br />bingo manager. <br />Page -1- <br />