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<br />- Gambling license Application Page 2 <br /> Type of Application: OClass A DClass B DClass C DClass D <br /> iHYes CJNo 23. Is gambling premises located within city limits? - .. . <br /> - <br /> KVes ONo 24. Are all gambling activities conducted at the premises listed in , 19 of this application? If not, complete a separate <br /> application for each premises (except raffles) as a separate license is reQuired for each premises. <br /> I DVesjl{No 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. <br /> i <br /> DVes~No 26. Does the organization lease the entire premises? If no, attach a sketch of 27. Amount of Monthly Rent <br /> the premises indicating what portion is being leased. A lease and sketch l$hSIJ~ I <br /> is not required for Class 0 applications. <br /> DVe.~o 28. Do you plan on conducting bingo with this license? If yes. gi\l'e days and times of bingo occasions: <br /> 0." ,.."., <br /> Ve.ONo 29, Has the $ t 0,000 fidelity bond required by Minnesota Stetutes 349.20 been obtained? Attach copy of bond, <br /> 30, <br /> ~< <br /> 32, <br /> .s ui' P <br /> 35, Gambling Manager Name <br /> S <:,Afj ;<' <br /> 38. Gambling Manager Business Phone 39, Date gambling manager became <br /> ( ,,( 2.-) - ~ r member of organization: I ('i'7IJ I <br /> GAMBLING SITE AUTHORIZATION <br /> By my signature below, local law enforcement officers or agents ofthe 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 />i practice. <br />I BANK RECORDS AUTHORIZATION <br />I By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account <br />.. whenever necessary to fulfill requirements of current gambling rules and law. <br /> OATH <br /> '.,1 hereby declare that: <br /> 1, ; I have read this application and all information submitted to the Board; <br /> 2. All information submitted is true, accurate and complete; <br /> 3. All other required information has been fully disclosed <br /> 4, lam 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 ofthe State of Minnesota respecting gambling and rules ofthe Board and agree, <br /> if licensed, to abide b those laws and rules, includin amendments thereto. <br /> 40, Official, a! Name of Organization 41. ~7ure ~ .b~nell by Chief Executive Officer I <br /> ~-- ;:- -~- I X' \ .& . <br /> .j <br /> Date <br /> ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br /> ( hereby acknowledge receipt of a copy of 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 receipt (noted below!. unless a resolution of the local governing body is passed <br /> which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control <br /> Board within 30 da s ofthe below noted date, <br /> 42, Na e ~f City or County {local Governing od I If site is located within a township, item 43 must be completed, in <br /> addition to the county signature. <br /> 43. Name of Township <br /> Signature of person receiving application <br />. X <br /> Tltle <br /> CG-DOO1 .()2 18/861 White Copy-Board Canary-Applicant Pink -Local Governing Body <br />