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! <br /> <br /> Gambling Manager Application <br /> <br />! <br /> <br />I <br />I <br /> <br />FOR OFFICE USE ONLY <br />FEE <br />CHK <br />DATE <br />INIT <br /> <br />Name; LAST FIRST MIDDLE MALDEN ] Dateof Birth <br /> <br />Add~ess State 71p Code <br /> <br />Membership: Date gambling manager became a member of the organization ._.~/. {==~ / 4~.~ Sex: <br /> <br /> Soc. Security Number <br /> <br /> Business Phone <br /> <br />~'Male 1'-1Female <br /> <br />I <br />I <br /> <br />Legal Name <br /> <br />Address Phone <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br /> [] New Give date alat gambling manager seminar was completed, i /;;~ / ?0 <br /> Location of training ~""~. C_.,~,O~,.~, , <br /> <br /> [] Renewal Give date of training received within three years pdor to the date of the application for renewal. __/ / <br /> Location of ~'aining <br /> <br />,.,,,,.,_,~,,~. ~,,,,,~,:~...:.~::.,~ ................... ,~..:.:.:..~,.~ .......... .~:.:...?..:.:~.:~.~,,:.:~.:,.:.:~.:.:,~ ............. ~::.::::..,.:,...:.:~,..~,. ................. :.. ................................................................................................... <br /> <br />- - A $10,000 fidelity bond in favor of the organiza~on must be obtained by the gambling manager. <br />Name of insurance company (do not use agency name) '~A'~ ~~"~ Bond Numher <br /> <br />- - A $~$.0~0 t~ bond in tarot et tho ~tate el Minnesota mu-~t be obtained by the organh, ation. The original oop¥ mu~t I~ submitted <br /> with thla ~pIi~flon. <br /> <br />Name of insurance company (do not use agency name) S'-~-'~-- ~ Bond Number <br /> <br />I ciectare <br /> <br />· I have read this application and all information submitted to the board; <br />, All information is true, acodrate and complete; <br />· All other required information has been tully c~sclosed; <br />· I am the only gambling manager of the organization; <br />· I will familiarize myself with ~ laws of Minnesota governing lawful gambling and rules of the board and agree, if licensed, to <br /> abide by those laws and rules, including amendments to ~em; <br />· Any cflanges in spplication information will be submitted to the board and IocaJ 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 deniaJ or revocation of the license. <br /> <br />I <br />I <br />I <br /> <br />Refq~'to the insll~uctions for the required attachments and fee. <br /> <br /> Department of Gaming <br />Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Roseviile, MN 55113 <br /> <br />Date <br /> <br /> <br />