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<br /> fC!Rc~()~t\F3P~lJSE ONLY_ ,..
<br /> MII~NFS()IA DEf'Mll MHI I or (,AMIN(; [lk,...nse Number J
<br /> (,AMl1UNG CONTilOL DIVISION --.- - ---,--_.. --..-.- ._---~--~
<br /> !\:1;lil Stillion 331 ~l rAID
<br /> SI 1',ltIL MN 5G11lG 3]15 AMf --------- .
<br /> (;17 7<) 7 5300 CHECK 1/ ._----_.~----
<br /> DATE _._----~.-
<br /> _.n"___'_~
<br /> GAMBLING LICENSE APPLICATION
<br /> INS 1111 ff: liONS
<br /> ..\ Ill'!> (II plll1[ ill Illk
<br /> " I Ii" (!'"\pli'l,'d ;Jf'I>!" ;J!!PI! Ifl 1'11;11 C1"\I('lllilln hody. ohl"in <;H1Il:11IHP <11)(! r!.'llP (jll illl copip<;, '11\(1 1(';lV~ 1 copy.' AppliciJnt keens 1
<br /> ("1'\ ;Inrl ';"tlrj--; (\!Iqin;illn tllf' ;lhr>\'" ;HldIP~':; vvill1 oj cl1f'Cy. I
<br /> IllI'llIllpl"I" ;lpplic;lIi"'l'~ In:l\, !1I' 11'1111 IH'rl
<br /> I) r I" l(l'~" lll'('rl<::r' r"l' \\'1111 :11 'pI ir:;l1 inn I
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<br /> ~'"f'\I'I'I''''f''''' I
<br /> CI;p':r; ^ r ('(' S700 OU millOO, n,lff!I;<;, r\HJrll(lwIH-(\l~_ lipho;lId~. rllll l[lhs)
<br /> Ki'\CI:l'~r: n If'>: $125 no (fblflp;" rnddlpvvlll,....Ic;, rir,hn;nds. rldl Inlls) Mtlkp. t:her.ks rnvnbll'" 10'
<br /> I I C1:1~:-~ L I I'fl $1 DO.OO ([3ill!/() Im!v) Commissioner of Revenue ,
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<br /> 1'('1:1.-:<::11 f r'.... ~7:-i nn m:,ro(';. flll!V) I
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<br /> Cllf',"h n11'" K 11\ ()lq:lllll:1t11l11 11;1e; IH'Vi'f h""11 lir"'tlsnrf
<br /> 1(~ r-r"I' ':11<, (~i\'" I':I'~" I il"i'11r;" n\IlllIH'1 l -_J
<br /> Illr' n"11"I' ;111'/ f'...i';1111(1 1jr"'II~r' (;iv'-' Cr1I1lpl"ll'" lin'I)~f" l1t!ll1h(~r [ I I ~~ __ ___J [--J
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<br /> 1 I 1- .--. -'--1 - r-- - .']
<br /> l'lfl ('11:),,'1" In ('1,1:.:'= nf :1'1 PYI';IIII(] 1,1;"l\"I~ (;11.''' ("(lll1JlI..tr? liCCI1<;(> nlllllllnr .-..,.....-- ~--------
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<br /> )"1'''= X Nfl ;, lfl': I'lq1111,--'111)11 f'VI'I '''':''llf-rj;, \nwhd C;:llllbl!n() FVf'tllplillll PI'flllil frOIn 11le Rni'lfd? If yes. give complete
<br /> I I I
<br /> 1"'111111 'lll'ld"'1 I
<br /> ----~_._._------ f
<br /> Yf'~ X No , 1]:1\1' IllI"Tn:1! (:(\1111<11;; h"PII '~ld\ll1itli'd I"P,"'inll~l\" Iln;, fnrllllHovidr:d bV tht' Board? If no, please attach copy.
<br /> .----- ---~._._-"----_.
<br /> '\1'1"11 dill (( lffi, ,;11 I('\ldl (1;1'1\1' or <1lq:1I1I/:1(Il"11 :; nl I":II1"",S ^ddl rs') of Org;lnI7<l!ion
<br /> C:,I1. IINITlm, INC:. 1'.0. BOX 6658 -~,
<br /> " , II ':!.II" /11' 7 r:rll_II\ly I~. 61'2"'"lS7716~f(Hfb~r~--- . I'
<br /> r~T "^IJI., tiN S'}J()(l HMI,sEY
<br /> q 1,,1'" <>1 rll(!lIll,:I!II'n 11;11"111:>1 f '1.:", I i' I ~! I I': l'-ln!'liqi()II'~ ;Opf!lf~r !ltll1plofit I
<br /> .-- --------- -- --~-,--
<br /> )f VI'S l' Nn I" I: "'!FU1I;,11!''!) T1lf"I,rpOI:1!('d ;I~ ,1 rHlllprplil (l\q:1l1i7,11inni' If yPS, qivr> number assigned to Articles or page and I
<br /> h:lnk 11111111"'1 i !~2()607 I ^ttncll copy of certificAte. ,
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<br /> X Y"'i No II AI" ;)rllr I,": 1111'<1 \\'111\ 111(' S""1r'1:1IV of St.1fr') ,
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<br /> X Yes No 17 t,:; (\Iq:lrli.i:lfif\/I f'''f'rnJII!rrl!1l r\:lIlHl"'~()Ll (]I r"lip!;"')] illcnlllf' lnx~ If Vrs, ple.1se attach letter from IRS or
<br /> I1f'II;11! ""-'1 II I If [1"\/"1111" rlpf'I;11 illq f-'(onlpl iOl1
<br /> ---. ~__________._ .......~"_n
<br /> YI':<:: 'XX'ln 1:~ 11:1<::, li,'I'iI -,. ",'I'I 1''''''1 d"!1i,-'d. SIIc,I"'lldr'd (]I ff"\,(lk,"I:-lf V('S, clleck all Ihal_ ~pp!y _
<br /> i 1 Df'lll<"1 ~~~llf:r\f'I)d('d r 1 flevllk,,(i fJilp di"ll~ i .J
<br /> i lS ------.-.--.. ..--- ----.,,--..----- .~_.-
<br /> 1 f r hllld"'I "r :)<'11\/(\ IIII'III),"! <"; Nllli>!'''! of v";u S in F'XI~ll"'ll('r:- Note: Attach evidence of
<br /> Vi 1<) thre,e years existence.
<br /> SEE_pj'.:J;'trLCOn_QLJlICL~
<br /> I': r J P'I" rd I 1\l<'f ['("('lill'" r 1111(""1 [r::1[)lI,'! I,', 11 N:1IIl(' Ilf llf>;\SIII"r or person who nccounts for other
<br /> r; 1,'dd"lq r. ];IT I."Hl' 'd I"W'llIJ"S III fhl> (lrgilr1iwliol1 (Cannot be Gambling Man<lger)
<br /> "HANK P. SE,^ I ANN I J).H. nTLLER
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<br /> 1111., f?~ Tilll"'
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<br /> 1'ln::;IIlFJ,T THI\M31.lfmn
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<br /> P'I'"ll''' 1 11'1I11,rllli\1l" 81Isi!l(>SS rlH)flP NIJlnber
<br /> ___.Li'.U I 1.82-')I,jf) ( 612 I q8B-1355
<br /> I;; IJ'III"''! ';I:lIdi':llt1H'111 '..-11' Ie> q;lrl,I,lii)(l \\';II!,., r'(\l1OIII('I!,(1 1~ Slr(:pl nrlrhl"'ss jllnl PO Box Number)
<br /> MmEN HILLS HALL 3776 CONNELLY_AVE. .......--.-..-- .--. --_.._-----"_._--~ .
<br /> 'n III., ':1;11" 71[1 71 C(\IHl\V h~,dl"!n tF11nhling premises is 'oeilled)
<br /> ARDEN T1l LLS , l1N 55U2 RNl,sEY I
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<br /> "TI'l! ("ll! '~'q \'!1I1" ( "1'\' P"'"!'d ( 111:11 \, '^llpll' ;lil! Pink-LoC;ll Governing Body
<br /> f';1qf' 1 of?
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