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City of Arden Hills License No. GAM012- <br /> 1245 West Highway 96 Receipt No. <br /> Arden Hills, Minnesota 55112 Amount Paid $150.00 <br /> -ft EN HILLS Phone: 651.792.7800 Date Recvd. <br /> Fax: 651.634.5137 Ins. Cert. <br /> www.ci.arden-hills.mn.us Total Fee Paid <br /> 2012Charitable Gambling Premise Permit- <br /> Application Form <br /> (Terms of the License: 2 Year Agreement) <br /> Information (all fields are required) <br /> Business Name: i>VV l?—,- L' K,e _-W LIA;l G/? t °'0,)X' C I <br /> Property Address: <br /> Nature of Business: 0 c,u c- L G <br /> Local Contact: t t _tall_f Z ,q <br /> Business Phone: U Sl ' -7 T Business Fax: <br /> Email Address: Website Address: <br /> Federal ID#: ( S a <br /> Premise Permit and Investigation Fee $150.00 <br /> Please submit the following forms with vour application: <br /> *2011 Income and Loss Statement _ <br /> *Projected 2012 Receipts/Prizes _ <br /> *Form LG200B Organization Officers Affidavit _ <br /> *Form LG214 Premise Permit Application _ <br /> *Form LG200R A preprinted renewal from the Gambling Control Board(if this is a renewal) _ <br /> *Form LG215 Lease for Lawful Gambling Activity _ <br /> *Copy of Lease Agreement _ <br /> *Insurance certificate <br /> (All organizations permitted to conduct lawful gambling within the City of Arden Hills shall contribute 10%(ten percent)of their <br /> net profits derived from gambling activities within the City to a special fund to be administered by the City Council for lawful <br /> purposes. Payments to the fund shall be calculated for quarterly periods ending on the last days of March, June, September and <br /> December.Quarterly installment payments shall be submitted together with verifiable supporting documentation no later than the <br /> twentieth day of the month following the end of the quarterly period.) <br /> Authorized Signature Date _c3l _ / <br />