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MINNESOTA LAWFUL GAMBLING 6/15 Page 1 of 2 <br />LG230 Application to Conduct Off-Site Gambling No Fee <br />ORGANIZATION INFORMATION <br />Organization Name: rrl &k, I vic: License Number: 002 CI <br />Address: 1 )C) 1'(4- 6o eI:' Lx"s CI City: ikt drl(1I 5 i MN Zip: <br />Gambling Manager Name: r ' 'C aL/5C L Daytime Phone: ("e, S <br />Chief Executive Officer(CEO) Name: 1 I"l W a ] ggrJL-s l e L Daytime Phone: &1 4D /'&ZOn <br />GAMBLING ACTIVITY <br />Twelve off-site events are allowed each calendar year not to exceed a total of 36 days. <br />From 311ol /6to ' / 6 / <br />Check the type of games that will be conducted: <br />Raffle Pull-Tabs Bingo Tipboards Paddlewheel <br />GAMBLING PREMISES <br />Name of location where gambling activity will be conducted: F/C,r' <br />Street address and Ave, 4(JJ I '`/ //City (or township): Zip: I/Z County: aM.5e <br />Do not use a post office box. <br />If no street address, write in road designations (example: 3 miles east of Hwy. 63 on County Road 42). <br />Does your organization own the gambling premises? <br />Yes If yes, a lease is not required. <br />No If no,the lease agreement below must be completed, and signed by the lessor. <br />LEASE AGREEMENT FOR OFF-SITE ACTIVITY (a lease agreement is not required for raffles) <br />Rent to be paid for the leased area: $if none, write "0") <br />All obligations and agreements between the organization and the lessor are listed below or attached. <br />Any attachments must be dated and signed by both the lessor and lessee. <br />This lease and any attachments is the total and only agreement between the lessor and the organization conducting lawful <br />gambling activities. <br />Other terms, if any: <br />Lessor's Signature: Date: <br />Print Lessor's Name: <br />CONTINUE TO PAGE 2