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<br /> - . <br /> G(1mblil1g License Application <br /> Type of Application: o Class A Il\I Class B o Class C o Class D <br /> KKYes 0 No 22. Is gambling premises located wi1l1in city Hinds? <br /> X'KVes [J No 23 Are <lll g[lmbling nctivities conduclerl at the plPlnises listed in fl18 of this application? If not, complete a separate <br /> . [] Yes J(J)(J\Io application for 8<lcll premises (except r<1ffles) ns {J sep<Hnte license is required for each premises. <br /> 24. Does orgnninltion own the gambling prerlliS8S1 If no, attach copy of the lease with terms of at leBst one year, <br /> and attach a sketch of the premises indicnting wl1<l1 portion is bp.ing leased. A lease and sketch are not required <br /> for Class 0 applications <br /> 25. Amount of nellL Pm 26 00 YOll plnll on conducI1I1Y !mlqo wlll\ Illis license7 If yes, give cloys and times of bingo occasions. <br /> Month or Bingo Occnsiol1 O;lY 1il11P OilY Time Day Time <br /> 1$ ~ ...--.---- <br /> '1/J1} . iJP <br /> _.__.M_'___"_.'~ . <br /> xxYes [J No 27, Has the $10,000 fidelity bond required by Minn~~sota .Stalutes 349,20 been obtained? <br /> 28_ InslHtlnc(! (OIllPrmy Nnll1c (not ilw~ncy nilll)!':>) Bond Number <br /> S,],~IE SURETY <br /> 30 Lpssor NamE' 31 Addlp.ss 32, Clly, State, Zip <br /> 33 Gfll11bling MfltlflgCI NalT10. 3~ Address 35 City, Swte, Zip <br /> ROBERT A. GRAY 5948 WASHBORN AVE. N. BROOKLYN CTR. MN 55430 <br /> 36 GrHl1blin~ Mnllflger Busillf~SS Pl1oll(~ 37. D<11e garnblinn fll~1flager becnme I Month 6 I <br /> 612 560 3364 member of org;Hllzation: 10/6/80 Year 80 <br /> xXVes 0 No 38. H<15 l!le license termin,Hlon form been completed? Attach copy. <br /> )(XVes 0 No 39. Has the compensation schedule been upproved by the organization? Attach copy_ <br /> ~O ListtllC day and timp. of the regulclT mee~i_llg of the organi7ation Dny - lS'CSWllAY Time 1:30 PM <br /> --~ .., ___u_.._____._______ <br /> 41 8<1 nk N<1 mp.- 42 Bank Address 43 Bank Account Number <br /> 4061 N. LEXINGTON AVE. <br /> ROSEVILLE STATE BANK ARDEN HILLS, MN 55126 24-56757-01 <br /> GAMBLING SITE AUTHORIZATION <br /> B~l my sign<1turl~ below, loc(lII;1\!V enforcPInp.nl officers or agents of the Boord are hereby authorized to enter upon the site at any <br /> . tillle \J"l1lhlin\1 is heing cOIHlllctcd 10 ohserve the \]ill1lhlill\] ilnd 10 enfo'ce the law for any unautho,ized game or practice, <br /> BANK RECORDS AUTHORIZATION <br /> By rllY signature below, 1fH-~ l3oi1rd is Il(~lcby ;lllll1orlZ(~d to inspect tile bank records of the gambling bank account whenever <br /> neC;CSS<1ry to fulfill requirements of current gfllllbling rules nne! IClw <br /> I hereby dp.-clnre that OATH <br /> 1 I have rcad this application <lnd all infmnwlion submitted to the Boarn; <br /> 2 All inforrn;ltion submitted is lrue, f1ccur<11e ilnd cornpletp.; <br /> 3 All other required inforlTlntioll Iws been fully disclosed; <br /> 4 I (1111 the r;hief executive officer of tile orgnlliz;:nion; <br /> 5 ! <1SSUI11€ full responSIbility for the fair <1lld Illwful ollcralion of <111 <lctivities to be conducted; <br /> 6 ! will familiiHize myself with tile laws of the 51<110 of Millnesotil respecting gambling and rules of the Board and agree. if <br /> licensed, to Abide by those laws and rulf-~s, including All1endmcnts thereto; <br /> 7, Membership list of the organization will be_~_vaiJab0_~ithin seven days after it is re <br /> ~~ Officifll, Leqal Nrlll1e of Orn<1ni7(ltion 4~tllre;:;LJst <br /> C.B.UNITED, INC. <br /> Title of Sigllf'r D<1le J- ~..-- ?,O <br /> Ilr''s,'/cj- <br /> ACKNOWLEDGEMENT OF NOTICE BV LOCAL GOVERNING BODV <br /> Illereby ,lCknowledge receipt of a copy of lhis arplication. By acknowledging receipt, I admit having been served with notice that this <br /> ('lpplicatioll will bp. reviewed by the Chilritablp. Gambling Control Bomd (lne! if <1pproved by the board, will become effective 60 days <br /> frolll the date of ff.~ceipt (noted below)un!ess (l rpsOhllio/l of the )ocal UOVf~rning body is passed which specifically disallO\Ns such <br /> activity and a copy of thilt resolution is received by the Charitable Gamblin Control Board within 60 da 5 of the belavv noted date. <br /> -16 Nfllllf'! of City or County (Loc;ll Governing Rody) If site is located within a township, item 47 must be completed, <br /> in fl(klition to tile county signature. If township is not organized, <br /> (:q_yntY.~D_~~t .$lg!~. ---.-.--.-.-.-." <br /> Siqniltllrc of person rf'ccivino nppli(~ati(ln 47 Name of Township <br /> X <br /> ---- <br /> .fltln Daln recr:ived (GO day p(~rt(ld Signiltllre of person receiving application <br /> Ilcqins from tlli~; d;l!(') <br /> X --.-------- <br /> ~8 Nllllm of [H'ISOn df'l1v(~rinn ilpplic,ltioll 10 L(1(~:ll (~(lv('rIWln Body Tillc <br /> -- ---~_.,_.__._--- <br /> cG (1(101 03 13 89) Whirf' Cnpv [loind CInar V AppllCilnl Pink-Local Governing Body <br /> Panp- 2 of 2 <br /> ."_.. <br /> - <br />