09-22-1993 Council Agenda - Laserfiche WebLink

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LG212GMR PRINTED: 09/10/93 STATE OF MINNESOTA GAMBLING CONTROL BOARD GAMBLING MANAGER LICENSE RENEWAL APPLICATION FOR BOARD USE ONLY AMT. PAID CHECK # DATE LICENSE NUMBER: G -01878 001 EFFECTIVE DATE: 03/01/93 EXPIRATION DATE: 02/28/94 NAME OF ORGANIZATION: Lions St Paul North Ramsey 500th Club :?1.(7) I eneaus William Massman 365 Koehler Rd Vadnais Heights MN 55127 GAMBLING MANAGER INFORMATION DATE OF BIRTH: 01/23/27 SEX: M SOCIAL SECURITY NUMBER: 469 -30 -5260 DAYTIME PHONE NUMBER: 612- 426 -0702 MEMBER SINCE: 10/06/77 LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR /CONTINUING EDUCATION CLASS: 03/30/90 BOND INFORMATION BOND COMPANY NAME: Cap Fidelity BOND NUMBER: CC555072 ACKNOWLEDGMENT I DECLARE THAT: • I HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD; • ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE; • ALL OTHER REQUIRED INFORMATION HAS BEEN FULLY DISCLOSED; • I AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION; • I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS; • I WILL FAMILIARIZE MYSELF WITH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF THE GAMBLING CONTROL BOARD AND AGREE, IF LICENSED, TO ABIDE THOSE LAWS AND RULES, INCLUDING AMENDMENTS TO THEM; • ANY CHANGES IN APPLICATION INFORMATION WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE; • AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHED; AND • I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LICENSE. SIGNATURE OF GAMBLING MANAGER DATE CLY REFER TO THE CHECKLIST FOR REQUIRED ATTACHMENTS MAIL TO: GAMBLING CONTROL BOARD 1711 WEST COUNTY ROAD B, SUITE 300S ROSEVILLE, MINNESOTA 55113 /03 THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST. Page 48