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<br /> . Gambling Ucense Application Page 2
<br /> Type of Application: DClass A JPClass B DClass C DClass 0
<br /> 'fJYes :JNo 23. Is gambling premises located within cFty limits?
<br /> :flYes :JNo 24. Are all gambling activities conducted at the premises listed in 119 of this application? If not, complete 8 separate
<br /> application for each premises (except rafflest 8S a separate license is required for each premises_
<br /> DYes' 0 25. Does organization own the gambling premises? If no, anach copy of the lease with terms of at least one year.
<br /> DYes ~o 26. Does the organization lease the entire premises? H no, attach a sketch of 27, Amount of Monthly Rent
<br /> the premises indicating what portion is being leased. A lease and sketch Is 806,67 I
<br /> is not required for Class D applications.
<br /> DYes iXNo 28. Do you plan on conducting bingo with this license? If yes. give days and times of bingo occasions:
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<br /> , [JCI'es 0 No 29, Has the S 1 0,000 fidelity bond required by Minnesota Statutes 349,20 been obtained' Attach copy of bond
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<br /> I 30, Insurance ~Q~afY ~ame 131. Bond Number
<br /> I conso ~ a e Agency Inc. 89985
<br /> 32. Lessor Name 33, -tsddress 34, City, State,Zip
<br /> Tnomas G. cossack 33 NO. Lexington Arden Hill 55112
<br /> ! 35. J;amblini Manaper Name ~. tddress 37, City, State. Zip
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<br /> I 0= . S encer 1 1 Edgcumbe #1712 st. paul 55105
<br /> 38. Gambling Manager Business Phone 39. Date gambling manager became 19:.8
<br /> I ( 099 189Jo member of organization: 1 I
<br /> ; GAMBLING SITE AUTHORIZATION
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<br /> I By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site,
<br /> , at any time, gambling is being conducted, to observe the gambling and to enforce the law for any unauthorized game or
<br /> , practice,
<br /> BANK RECORDS AUTHORIZATION
<br /> . By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account
<br /> whenever necessary to fulfili requirements of current gambling rules and law.
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<br /> i OATH
<br /> I l'hereby declare that:
<br /> I ' . I have read this application and all information submitted to the Board;
<br /> I 2, All information submitted is true, accurate and complete;
<br /> 3. All other required information has been fully disclosed
<br /> 4, I am the chief executive officer of the organization;
<br /> 5, I assume full responsibility for the fair and lawful operation of all activities to be conducted; ,
<br /> 6. I will familiarize myself with the laws of the State 01 Minnesota respecting gambling and rules 01 the Board and agree,
<br /> if licensed, to abide b those laws and rules, includin amendments thereto.
<br /> I 40, Official, Legal Name of Organization 41. Si ureln\' t ~ Si7f:d hief Executive Officer)
<br /> ORIGINAL BOOSTERS X
<br /> Title 01 Signer PRESIDENT Date
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<br /> ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br /> I hereby acknowledge receipt of a copy 01 this application. By acknowledging receipt, I admit having been served with
<br /> notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, Will
<br /> become effective 30 days from the date of receiptlnoted below!, unless a resolution of the local governing body is passed
<br /> which specilically disallows such activity and a copy 01 that resolution is received by the Charitable Gambling Control
<br /> Board within 30 da sol the below noted date,
<br /> 42, Name of City or County (Local Gov rning BOdyl If site is located within 8 township, item 43 must be completed, in
<br /> addition to the county signature.
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<br /> I 43, Name of Township
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<br /> o te received (30 day period Signature of person receiving application
<br /> begins from this datel 'l/5/B? X
<br /> 44, Name of Person delivering application to Local Governing Body Title
<br /> CG-0001~2 181861 White Copy.Boa,d Canary -Applicant Pink .locat Goveming Body
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