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Bingo Hall License Application (CG300) - Part 2 <br />Owner /Lessor Information <br />6. Have /do any persons listed in items 4, 4a, 5, and 5a: <br />a. been convicted of a felony in the last five years? <br />Yes <br />No <br />x <br />b. ever been convicted of a felony Involving fraud or misrepresentation or a crime involving gambling? <br />x <br />c. owe delinquent taxes in excess of $500 as defined in Minnesota Statutes section 270.72? <br />x <br />7. Are any of the individuals listed in items 4, 4a, 5, and 5a a licensed distributor, licensed manufacturer <br />or an affiliate of a distributor or manufacturer of gambling equipment or a wholesale distributor of <br />alcoholic beverages? <br />X <br />Oath <br />I declare that this application is correct and complete to the best of my knowledge and belief. I will familiarize myself with the laws of the <br />state of Minnesota and rules of the Board regarding gambling and agree, if licensed, at/abide by those laws and rules, including amend- <br />ments to them. Changes in the information submitted in this application will be submitted to the Board and local government unit within ten <br />days after the change occurs. <br />8. Signature of ..'ef <br />9. Name of person completing this form Title Phone <br />orYn cllZ�e T- (61 ).)933 Asia <br />Acknowledgement of Notice by Local Governing Body <br />(The city' must sign If the bingo hall Is located within city limits. The county "AND township" must sign If the bingo hall Is <br />located within a township.) <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Board and Department of <br />Public Safety, and may become effective not less than 60 days from the date of receipt by the city or county, unless the local <br />government passes a resolution to deny the activity. A copy of that resolution must be received by the Gambling Control <br />Board within 60 days of the date listed below. If the local governing body (city or county) chooses to waive its right to deny <br />the license within the 60 day period, the local governing body must notify the Board in writin of the waiver. <br />City* or County" <br />Township** <br />10. City or county name <br />Crity 07 ( r / //e Cn.v•.O4 <br />11. Township name <br />Si nature of person re ivin9�appplication <br />• <br />Signature of person receiving application <br />Titl <br />/y c%n,,..rk,/*r <br />Uate received (60 day penod <br />begins from this date) <br />A.JU 29 /9 5`o <br />Title - Township official Date received <br />ame of person delivering application to local govemment <br />Is township? organized unorganized unincorporated <br />I I I <br />Binao Hall Application and required attachments; <br />-Form 03300, Bingo Hall License Application, Parts 1 and 2 <br />*Form CG302, Bingo Occasion List <br />form CG315, Bingo Hall Personnel Information <br />(for each person listed in items 5, 5a, 6, and 6a <br />Check for license fee of $2,500, made payable to <br />"Commissioner of Revenue" <br />on form CG300) <br />Where to mall the application and attachments <br />Department of Gaming <br />Gambling Control Division <br />Mail Station 3315 <br />St. Paul, MN 55146.3315 <br />Page 22 <br />