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LG212 <br />(11/1/90) <br />Minnesota Lawful Gambling <br />Gambling Manager Application <br />Gambling Manager Information <br />Name: LAST FIRST MIDDLE <br />Massma n <br />Address <br />365 Koehler Rd. Vadnais Htg. <br />1reneaus <br />MAIDEN <br />William <br />State <br />FOR OFFICE USE ONLY <br />FEE <br />CHI< <br />DATE <br />INIT <br />Date of Birth <br />1/23/27 <br />Soc. Security Number <br />469 -3o -5260 <br />Zip Code Business Phone <br />55127 426 -0702 <br />Membership: Date gambling manager became a member of the organization 1.0/ 6 /77 <br />Sex: [Ili/tale ❑Female <br />Organization Xnformat on <br />Legal Name <br />North Ramsey 300th Lions Club <br />Address City <br />P.O. Box 17031 <br />:type of Appt eatiot <br />St. Paul Minn. <br />426-0702 <br />Phone <br />❑ New Give date that gambling manager seminar was completed. 3 / 30 90 <br />Location of training <br />Sunrr od (LN)n St. Paul Mn. ct <br />• Renewal Give date of training received within three years prior to the date of the application for renewal. / / <br />Location of training <br />(dry) <br />Band Infolmiatiott . <br />- - A $10,000 fidelity bond in favor of the organization must be obtained by the gambling manager. <br />Cap. Ind. Corp <br />Name of insurance company (do not use agency name) Bond Number r1 -- n r, n <br />-- A $15,000 tax bond in favor of the state of Minnesota must be obtained by the organization. A copy must be submitted with this <br />application. <br />Name of insurance company (do not use agency name)- rs „ 'rat rpr^ Bond Number rr C r <br />vwkmi w edgt <br />declare that: -- <br />• I have read this application and all information submitted to the board; <br />• All information is true, accurate and complete; <br />• All other required information has been fully disclosed; <br />• I am the only gambling manager of the organization; <br />• I will familiarize myself with the laws of Minnesota goveming lawful gambling and rules of the board and agree, if licensed, to <br />abide by those laws and rules, including amendments to them; <br />• Any changes in application information will be submitted to the board and local government within 10 days of the change; <br />• An affidavit for gambling manager has been completed and attached. <br />• Failure to provide required information or providing false information may result in the denial or revocation of the license. <br />Sign re of Gambling Manager <br />cater to the instructions for [Ke / rdquired attachments and fee. <br />Page 36 <br />Date <br />Department of Gaming <br />Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road 13 <br />Roseville, MN 55113 <br />