97-784Council File # �`�
Ordinance #
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' f���='sn`r�, �
<�� E�:;Lr�'4�
` '4
Presented By
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Green Sheet # 35344
���
RESOLVED: That application, ID #64247, for a new Gambling Manager's License by Lois J.
Dirksen DBA Se�cual Violence Center at Club Metro, 733 Pierce Butler Route, be
and the same is hereby approved.
Requested by Department of:
• # .- • -� - : .-• •�- .�:
! 1' - • S
f
� k •� ��
Adopted by Council: Date \ °�'�
Adoptio by Council Secretary
By: 11 \ c�- . � �is--��
Approved by Mayor: Date Z/�"!`� �
B � �-- c �%��
Form Approved by city � t��rce�
p � J � )
By: V�2�v.t,a, � %�
Approved by Mayor for Submisaion to
Council
By:
�I'1-'1�4
DEPARTMENT/OFFlCFJCOUNCIL DAiE INITIATED GREEN SHEET N� 3 5 3 4 4 ,
LIEP _ , _ _
INfTIAVDATE INITIAVDATE
CONTACTPEFSON 8 PHONE Q DEPAFTMEf�f�DIRECTOR � CRYCAUNCIL
William F. Gunther - 266-9132 A���N O CRYATTORNEY O CITYCLERK
NUYBERFOR
MUST BE ON OOUNCIL AGENDA 8Y (OAi� pp�p� O BUDGET DlRECTOR � FItJ. 8 MGT. SEAVICES OtR.
/ �( ` ONDER � MqYOR (OR ASSI5TANn �
$edT1II : {v a[�
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCA710NS FOR SICaNATURE)
ncnori a[ouesreo:
Lois J. Dirksen DBA Sexual 4iolence Center requests Council approval for an
application for a new Gambling Manager's License at Club Metro, 733 Pierce Butler Route.
(ID �164247 )
FiECOMMENDAnONS: Appraue (A) w Reject (a) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING CAMMISSION � CIVIL SEfiVICE COMMISSIIXJ 1. Has ttiis perso�rm ever worketl under a corrtract for this departrnent? -
_ ae COn�MmEE _ YES "NO
�� — 2. Has Mis perso�rm ever been a city employee?
YES NO
_ DISTHIC7 CAURi _ 3. Does this personffirm possess a skill not normally possessetl by any curtem ciry employce?
SUPPORT$ WHICH COUNCIL OBJECTNE? YES NO
Exp�ain all yes answen on separete sheet and attaeh to green sheet
INIT�ATINGPSiOBLEM.ISSUE.OPPeJRTUNITY(Who.YMet.Wfien.Where.Why): '
� . � RECEIVE[�
JUN 12 1997 ���������%
lERRY BL4KEY Ju� o� �9s�
�-n �a � �
ADVANTAGESIFAPPROVEO:
DISADVANTAGES IFAPPqO�ED: �
JUN 1 21�97
OISADVANTAGES IF NOTAPPROVED:
TQTAL AMOUNT QF TRANSACTION $ COST/NEVENUE BUDGETED (CIRCLE ONE) VES NO
FUNDItdG SOURCE NC7IVITY NUMBEH
PINANCIAL INFORMATION: (EXPLAIN)
Greensheet #
In TrackeR___���[�
License ID # 64247
�`�
L.I.E.P. REVIEW CHECKLIST � c �� "� g y
ApP'n Received / ApP'n Processed
License Type: GamblinQ Manager
COmpanyName: Lois J. Dirksen DBA: Sexval p;olence ('Pntar
Business Addresss: 733 Pierce Butler Route (Club Metro) Business Phone: 9 8-47t t
Contact Name/Address: 410 Groveland Ave. �I302 Home Phone: 9�R—��� t
Date to Council Research: Minne� /�� 55403
Pubiic Hearing Date: �n.t �S !9� % Labels Ordered: N A
Notice Sent to Applicant: �v�LClQ`7 District Council #: 07
Notice Sent to Public: N/A Ward #: O1
Department/ Date Inspections Commenis
Ciry Attomey /� e' � � �/ /
�/�a/��
Environmenial
Health
�/ �
Fire
�� �
License Site Plan aeceived:_
Lease Received:
�� �
Police Q� �� �t 7'T2�C�
�/��g�
Zoning
/V l �
��zts Minnesota Gambling Control Board
04/18/95 Gambfing Manager Affidavit
Attach to the Gambling Manager Application, Form LG212
STATE OF )
q-►- �8y
m f Yl Y12 S� �-tA AFFIDAVIT OF QUALIFICATION
) s.s. FOR GAMBLING MANAGER LICENSE
COUNTY OF ' AND CONSENT STATEMENT
(-�f �'1 YlR-�� l h � (Pursuant to Minnesota Statutes and Rules)
i, LOIS �rcc,�n�lrk�sr.r� ,Underoathstatetfiat:
(type/print name) -
1. i have never been convicfed of a felony or a crime involving gambling.
2. i have not, within ive years before ihe daie of the license application, committed a viofation of law or
Board rule that resuited in the revocation of a license issued by the Board.
�. - ;: � :
3. i have never been convicted of a criminal viotation involving fraud, theft, tax evasion, misreprese�tatign, ,
or gambling.
4. I have never been convicted of n assauR, (i)_ a criminal violation involving the use, of a i
making fercoristic threats.
- .' .. — . "r•�' "���.� - ' _,. � � ` - _ . " l" ;', _. �rf
5. I am not, nor ever have been connected,'with or engaged,in�an iilegal business:.,. -�°s_:,,>;;
6. I do not owe $SOO,o�_more in deli
7. t have not had'_a sales and use te
years. - '
`; -
8. I have never afterdemand faile
-�� �� - .,'l.k��'�-a�:�f�'_:��-.�<.�?
i�.,�.;,1,+�ii.:..;�'..., ....s...,.i�_.:...,...,...,
`NC
Notary ?ut
Seal may_r
' : Subscribe
` -� � d
,� e
.,
i:'
i E.
� ,� j , r3
3
axes as defined in secfion 270.72.
t Cevoked,by the commissioner of revenue withi
i ` _ ..._. � . . ._ _ _ . .. __ . ,
�� 'ey
w - , . . 5 t �`.��Y1TY. k : � t` 3t �k ���,
'UBLIC lNFORMA770N �` � � �
t i,1 i a y s,rn �c i»3a �. (� - f .� iE . t•
must be cur�e�t and correct � _ ,; t _ 3° ,,,; - , -._ (signata�
tf:('Ed;:�LiG'fJ� M?e�' a. _s ::• „�7 . _�..>' ... ,. . : .--,.:, rd � , �,i.
+�,n�".+.�-�„�'ti. _ S f �'. �;v; 3�5 . � i <+
• � `'
�..�9�
� c ,
� { - f i�
s;°�, t ,
i>� ° F "i "� - -.� �. . -. . � : i:3, "•
, , �t�i�
ORGANIZJ
Jame of Organizati
�SexUuQ:;�i
cr��?:; � .-..
Fc:- .._-. ..
ro :.' ;. . _
i=
t'� . _ _ . - .
, ' ..
`.';:7�'
.
'_U „c.�:�F;
70N, _
�"
-,
�'�2
. ;-r .
LG272
(Rev. 7/Z92)
� -
� Renewal
LAST NAME
�D(�se�n
Address " ' �
Minnesota Lawful Gambiing
Gambling Manager Applicatio�.
es
FOR OFFICE USE ONLY
ensE uc � _�
SEQ z
FEE
CHK
DATE
INIT
Give date that the nvo-day garnbling manager seminar was completed. o/� �
Location of training �Q�Q/Y7J
(ciry)
Give date of training received within three years prior to tlie date of ihe application for renewal. _/ /
Locafion of training
FIRSTNAME MIDDLENAME
i.o � 5 J �a.r,
iv�_:� -� 30 2 (Y
Date of Birtfi Soc. Securiry Number
4-ta�ss 5�- a�-3��8
�y
MAIDEN
s��
m�
MEMBERSHIP.�Data_garnbling manager became a member of the organiza5on �/, `�( g7
_ .. . e��y ca�ai�ya� ui �mom
;. '_ _ r•c..u..._�... -
=;�;=.};= ::��. __�'Ari affid'a'vit for,gainbi�g;manage
-� .. .. � 1 understan"d Uiat failure to provic
Gcense:: �} a _ .
-, Signature of GambGng Manager �
- : G
r:r";.�{ i ::'.�;._.. ., -, . .
x7 i��aav: _; `
;';:;�;;.<:;,::<:M:=:<<:::<:.
I °'�
7�1r�
Send the completed appiication and aIl required attachments to:
Gambiing Control Board "
� � � - � ' , � �Sulte 300 S. -
t711 W..County Road B
° Ftosevllle, MN 55�73
- ` ;: -
. . _ , � � �_�, , .
+� . , ...-. .
Daytime Phone
�� �� 9� �!7//
Sex : � Male _ � Female
_ � , � � �,">-'
-7 j �O�l -����3e�9�fn f�,�`Il�
Council File # �`�
Ordinance #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
' f���='sn`r�, �
<�� E�:;Lr�'4�
` '4
Presented By
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Green Sheet # 35344
���
RESOLVED: That application, ID #64247, for a new Gambling Manager's License by Lois J.
Dirksen DBA Se�cual Violence Center at Club Metro, 733 Pierce Butler Route, be
and the same is hereby approved.
Requested by Department of:
• # .- • -� - : .-• •�- .�:
! 1' - • S
f
� k •� ��
Adopted by Council: Date \ °�'�
Adoptio by Council Secretary
By: 11 \ c�- . � �is--��
Approved by Mayor: Date Z/�"!`� �
B � �-- c �%��
Form Approved by city � t��rce�
p � J � )
By: V�2�v.t,a, � %�
Approved by Mayor for Submisaion to
Council
By:
�I'1-'1�4
DEPARTMENT/OFFlCFJCOUNCIL DAiE INITIATED GREEN SHEET N� 3 5 3 4 4 ,
LIEP _ , _ _
INfTIAVDATE INITIAVDATE
CONTACTPEFSON 8 PHONE Q DEPAFTMEf�f�DIRECTOR � CRYCAUNCIL
William F. Gunther - 266-9132 A���N O CRYATTORNEY O CITYCLERK
NUYBERFOR
MUST BE ON OOUNCIL AGENDA 8Y (OAi� pp�p� O BUDGET DlRECTOR � FItJ. 8 MGT. SEAVICES OtR.
/ �( ` ONDER � MqYOR (OR ASSI5TANn �
$edT1II : {v a[�
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCA710NS FOR SICaNATURE)
ncnori a[ouesreo:
Lois J. Dirksen DBA Sexual 4iolence Center requests Council approval for an
application for a new Gambling Manager's License at Club Metro, 733 Pierce Butler Route.
(ID �164247 )
FiECOMMENDAnONS: Appraue (A) w Reject (a) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING CAMMISSION � CIVIL SEfiVICE COMMISSIIXJ 1. Has ttiis perso�rm ever worketl under a corrtract for this departrnent? -
_ ae COn�MmEE _ YES "NO
�� — 2. Has Mis perso�rm ever been a city employee?
YES NO
_ DISTHIC7 CAURi _ 3. Does this personffirm possess a skill not normally possessetl by any curtem ciry employce?
SUPPORT$ WHICH COUNCIL OBJECTNE? YES NO
Exp�ain all yes answen on separete sheet and attaeh to green sheet
INIT�ATINGPSiOBLEM.ISSUE.OPPeJRTUNITY(Who.YMet.Wfien.Where.Why): '
� . � RECEIVE[�
JUN 12 1997 ���������%
lERRY BL4KEY Ju� o� �9s�
�-n �a � �
ADVANTAGESIFAPPROVEO:
DISADVANTAGES IFAPPqO�ED: �
JUN 1 21�97
OISADVANTAGES IF NOTAPPROVED:
TQTAL AMOUNT QF TRANSACTION $ COST/NEVENUE BUDGETED (CIRCLE ONE) VES NO
FUNDItdG SOURCE NC7IVITY NUMBEH
PINANCIAL INFORMATION: (EXPLAIN)
Greensheet #
In TrackeR___���[�
License ID # 64247
�`�
L.I.E.P. REVIEW CHECKLIST � c �� "� g y
ApP'n Received / ApP'n Processed
License Type: GamblinQ Manager
COmpanyName: Lois J. Dirksen DBA: Sexval p;olence ('Pntar
Business Addresss: 733 Pierce Butler Route (Club Metro) Business Phone: 9 8-47t t
Contact Name/Address: 410 Groveland Ave. �I302 Home Phone: 9�R—��� t
Date to Council Research: Minne� /�� 55403
Pubiic Hearing Date: �n.t �S !9� % Labels Ordered: N A
Notice Sent to Applicant: �v�LClQ`7 District Council #: 07
Notice Sent to Public: N/A Ward #: O1
Department/ Date Inspections Commenis
Ciry Attomey /� e' � � �/ /
�/�a/��
Environmenial
Health
�/ �
Fire
�� �
License Site Plan aeceived:_
Lease Received:
�� �
Police Q� �� �t 7'T2�C�
�/��g�
Zoning
/V l �
��zts Minnesota Gambling Control Board
04/18/95 Gambfing Manager Affidavit
Attach to the Gambling Manager Application, Form LG212
STATE OF )
q-►- �8y
m f Yl Y12 S� �-tA AFFIDAVIT OF QUALIFICATION
) s.s. FOR GAMBLING MANAGER LICENSE
COUNTY OF ' AND CONSENT STATEMENT
(-�f �'1 YlR-�� l h � (Pursuant to Minnesota Statutes and Rules)
i, LOIS �rcc,�n�lrk�sr.r� ,Underoathstatetfiat:
(type/print name) -
1. i have never been convicfed of a felony or a crime involving gambling.
2. i have not, within ive years before ihe daie of the license application, committed a viofation of law or
Board rule that resuited in the revocation of a license issued by the Board.
�. - ;: � :
3. i have never been convicted of a criminal viotation involving fraud, theft, tax evasion, misreprese�tatign, ,
or gambling.
4. I have never been convicted of n assauR, (i)_ a criminal violation involving the use, of a i
making fercoristic threats.
- .' .. — . "r•�' "���.� - ' _,. � � ` - _ . " l" ;', _. �rf
5. I am not, nor ever have been connected,'with or engaged,in�an iilegal business:.,. -�°s_:,,>;;
6. I do not owe $SOO,o�_more in deli
7. t have not had'_a sales and use te
years. - '
`; -
8. I have never afterdemand faile
-�� �� - .,'l.k��'�-a�:�f�'_:��-.�<.�?
i�.,�.;,1,+�ii.:..;�'..., ....s...,.i�_.:...,...,...,
`NC
Notary ?ut
Seal may_r
' : Subscribe
` -� � d
,� e
.,
i:'
i E.
� ,� j , r3
3
axes as defined in secfion 270.72.
t Cevoked,by the commissioner of revenue withi
i ` _ ..._. � . . ._ _ _ . .. __ . ,
�� 'ey
w - , . . 5 t �`.��Y1TY. k : � t` 3t �k ���,
'UBLIC lNFORMA770N �` � � �
t i,1 i a y s,rn �c i»3a �. (� - f .� iE . t•
must be cur�e�t and correct � _ ,; t _ 3° ,,,; - , -._ (signata�
tf:('Ed;:�LiG'fJ� M?e�' a. _s ::• „�7 . _�..>' ... ,. . : .--,.:, rd � , �,i.
+�,n�".+.�-�„�'ti. _ S f �'. �;v; 3�5 . � i <+
• � `'
�..�9�
� c ,
� { - f i�
s;°�, t ,
i>� ° F "i "� - -.� �. . -. . � : i:3, "•
, , �t�i�
ORGANIZJ
Jame of Organizati
�SexUuQ:;�i
cr��?:; � .-..
Fc:- .._-. ..
ro :.' ;. . _
i=
t'� . _ _ . - .
, ' ..
`.';:7�'
.
'_U „c.�:�F;
70N, _
�"
-,
�'�2
. ;-r .
LG272
(Rev. 7/Z92)
� -
� Renewal
LAST NAME
�D(�se�n
Address " ' �
Minnesota Lawful Gambiing
Gambling Manager Applicatio�.
es
FOR OFFICE USE ONLY
ensE uc � _�
SEQ z
FEE
CHK
DATE
INIT
Give date that the nvo-day garnbling manager seminar was completed. o/� �
Location of training �Q�Q/Y7J
(ciry)
Give date of training received within three years prior to tlie date of ihe application for renewal. _/ /
Locafion of training
FIRSTNAME MIDDLENAME
i.o � 5 J �a.r,
iv�_:� -� 30 2 (Y
Date of Birtfi Soc. Securiry Number
4-ta�ss 5�- a�-3��8
�y
MAIDEN
s��
m�
MEMBERSHIP.�Data_garnbling manager became a member of the organiza5on �/, `�( g7
_ .. . e��y ca�ai�ya� ui �mom
;. '_ _ r•c..u..._�... -
=;�;=.};= ::��. __�'Ari affid'a'vit for,gainbi�g;manage
-� .. .. � 1 understan"d Uiat failure to provic
Gcense:: �} a _ .
-, Signature of GambGng Manager �
- : G
r:r";.�{ i ::'.�;._.. ., -, . .
x7 i��aav: _; `
;';:;�;;.<:;,::<:M:=:<<:::<:.
I °'�
7�1r�
Send the completed appiication and aIl required attachments to:
Gambiing Control Board "
� � � - � ' , � �Sulte 300 S. -
t711 W..County Road B
° Ftosevllle, MN 55�73
- ` ;: -
. . _ , � � �_�, , .
+� . , ...-. .
Daytime Phone
�� �� 9� �!7//
Sex : � Male _ � Female
_ � , � � �,">-'
-7 j �O�l -����3e�9�fn f�,�`Il�
Council File # �`�
Ordinance #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
' f���='sn`r�, �
<�� E�:;Lr�'4�
` '4
Presented By
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Green Sheet # 35344
���
RESOLVED: That application, ID #64247, for a new Gambling Manager's License by Lois J.
Dirksen DBA Se�cual Violence Center at Club Metro, 733 Pierce Butler Route, be
and the same is hereby approved.
Requested by Department of:
• # .- • -� - : .-• •�- .�:
! 1' - • S
f
� k •� ��
Adopted by Council: Date \ °�'�
Adoptio by Council Secretary
By: 11 \ c�- . � �is--��
Approved by Mayor: Date Z/�"!`� �
B � �-- c �%��
Form Approved by city � t��rce�
p � J � )
By: V�2�v.t,a, � %�
Approved by Mayor for Submisaion to
Council
By:
�I'1-'1�4
DEPARTMENT/OFFlCFJCOUNCIL DAiE INITIATED GREEN SHEET N� 3 5 3 4 4 ,
LIEP _ , _ _
INfTIAVDATE INITIAVDATE
CONTACTPEFSON 8 PHONE Q DEPAFTMEf�f�DIRECTOR � CRYCAUNCIL
William F. Gunther - 266-9132 A���N O CRYATTORNEY O CITYCLERK
NUYBERFOR
MUST BE ON OOUNCIL AGENDA 8Y (OAi� pp�p� O BUDGET DlRECTOR � FItJ. 8 MGT. SEAVICES OtR.
/ �( ` ONDER � MqYOR (OR ASSI5TANn �
$edT1II : {v a[�
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCA710NS FOR SICaNATURE)
ncnori a[ouesreo:
Lois J. Dirksen DBA Sexual 4iolence Center requests Council approval for an
application for a new Gambling Manager's License at Club Metro, 733 Pierce Butler Route.
(ID �164247 )
FiECOMMENDAnONS: Appraue (A) w Reject (a) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING CAMMISSION � CIVIL SEfiVICE COMMISSIIXJ 1. Has ttiis perso�rm ever worketl under a corrtract for this departrnent? -
_ ae COn�MmEE _ YES "NO
�� — 2. Has Mis perso�rm ever been a city employee?
YES NO
_ DISTHIC7 CAURi _ 3. Does this personffirm possess a skill not normally possessetl by any curtem ciry employce?
SUPPORT$ WHICH COUNCIL OBJECTNE? YES NO
Exp�ain all yes answen on separete sheet and attaeh to green sheet
INIT�ATINGPSiOBLEM.ISSUE.OPPeJRTUNITY(Who.YMet.Wfien.Where.Why): '
� . � RECEIVE[�
JUN 12 1997 ���������%
lERRY BL4KEY Ju� o� �9s�
�-n �a � �
ADVANTAGESIFAPPROVEO:
DISADVANTAGES IFAPPqO�ED: �
JUN 1 21�97
OISADVANTAGES IF NOTAPPROVED:
TQTAL AMOUNT QF TRANSACTION $ COST/NEVENUE BUDGETED (CIRCLE ONE) VES NO
FUNDItdG SOURCE NC7IVITY NUMBEH
PINANCIAL INFORMATION: (EXPLAIN)
Greensheet #
In TrackeR___���[�
License ID # 64247
�`�
L.I.E.P. REVIEW CHECKLIST � c �� "� g y
ApP'n Received / ApP'n Processed
License Type: GamblinQ Manager
COmpanyName: Lois J. Dirksen DBA: Sexval p;olence ('Pntar
Business Addresss: 733 Pierce Butler Route (Club Metro) Business Phone: 9 8-47t t
Contact Name/Address: 410 Groveland Ave. �I302 Home Phone: 9�R—��� t
Date to Council Research: Minne� /�� 55403
Pubiic Hearing Date: �n.t �S !9� % Labels Ordered: N A
Notice Sent to Applicant: �v�LClQ`7 District Council #: 07
Notice Sent to Public: N/A Ward #: O1
Department/ Date Inspections Commenis
Ciry Attomey /� e' � � �/ /
�/�a/��
Environmenial
Health
�/ �
Fire
�� �
License Site Plan aeceived:_
Lease Received:
�� �
Police Q� �� �t 7'T2�C�
�/��g�
Zoning
/V l �
��zts Minnesota Gambling Control Board
04/18/95 Gambfing Manager Affidavit
Attach to the Gambling Manager Application, Form LG212
STATE OF )
q-►- �8y
m f Yl Y12 S� �-tA AFFIDAVIT OF QUALIFICATION
) s.s. FOR GAMBLING MANAGER LICENSE
COUNTY OF ' AND CONSENT STATEMENT
(-�f �'1 YlR-�� l h � (Pursuant to Minnesota Statutes and Rules)
i, LOIS �rcc,�n�lrk�sr.r� ,Underoathstatetfiat:
(type/print name) -
1. i have never been convicfed of a felony or a crime involving gambling.
2. i have not, within ive years before ihe daie of the license application, committed a viofation of law or
Board rule that resuited in the revocation of a license issued by the Board.
�. - ;: � :
3. i have never been convicted of a criminal viotation involving fraud, theft, tax evasion, misreprese�tatign, ,
or gambling.
4. I have never been convicted of n assauR, (i)_ a criminal violation involving the use, of a i
making fercoristic threats.
- .' .. — . "r•�' "���.� - ' _,. � � ` - _ . " l" ;', _. �rf
5. I am not, nor ever have been connected,'with or engaged,in�an iilegal business:.,. -�°s_:,,>;;
6. I do not owe $SOO,o�_more in deli
7. t have not had'_a sales and use te
years. - '
`; -
8. I have never afterdemand faile
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LG272
(Rev. 7/Z92)
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� Renewal
LAST NAME
�D(�se�n
Address " ' �
Minnesota Lawful Gambiing
Gambling Manager Applicatio�.
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FOR OFFICE USE ONLY
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DATE
INIT
Give date that the nvo-day garnbling manager seminar was completed. o/� �
Location of training �Q�Q/Y7J
(ciry)
Give date of training received within three years prior to tlie date of ihe application for renewal. _/ /
Locafion of training
FIRSTNAME MIDDLENAME
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Date of Birtfi Soc. Securiry Number
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MAIDEN
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MEMBERSHIP.�Data_garnbling manager became a member of the organiza5on �/, `�( g7
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=;�;=.};= ::��. __�'Ari affid'a'vit for,gainbi�g;manage
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Gcense:: �} a _ .
-, Signature of GambGng Manager �
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Send the completed appiication and aIl required attachments to:
Gambiing Control Board "
� � � - � ' , � �Sulte 300 S. -
t711 W..County Road B
° Ftosevllle, MN 55�73
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Daytime Phone
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Sex : � Male _ � Female
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