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<br />")"''''~'~'IIfJI~''f~'.1~!f~\~''~' <br />, ..,,'~ -~., -'0\;;;;'1. .;Prenuse ' ,emu", pp ca IOn <br />. .. "'~"'-""~' __-',7", <br /> <br /> Ba~k Name Bank Account Number <br /> FtRS(.If-/L 120) 'C (/ltL ~ rJ./-VL ;, 7- 200193 06 <br /> Bank Address City State Zip Code <br /> ?-l Q'>O '/.J . ') r1 ~u f/./C ~ )..<f:V ItL 'I. ik-A.J <;,-- 1/ 3 <br /> <br /> ame ress I e <br /> -- ,9;, (q-tr /U,- 5"" - 'iT . P;f<.J( 6-;fLr<~. /7&<1. <br /> J.,f./'t"- 5 C4-,O<;;.rl ,U. / <br /> fI-h L r.9~tU(f4- ~. RiJJ''it.lttlc.. CZ:.O. <br /> (J<(" I ');-I--,Opl/v.Rfr P.e, <br /> 1~.~llm[~I!II;III~1~fJ}t~11'11Iil!4111111Iii"JIII'.'11@Jllljllilllllilllljjlfitliiililiiil11IfIIJllltll!lllli <br /> 'Gambll;:;'g'siteAut'horlzation .1 am the chief executive officer of the organization; <br /> I hereby consent that local law enforcement officers, the .J assume full responsibility for the fair and lawful opera- <br /> board or agents of the board, or Ihe commissioner of 'Iion of all activ~ies 10 be conducted; <br /> revenue or public safety: or agents of the commissioners, .1 will familiarize myself with the iaws of Minnesota <br /> may enter the premises to enforce the law. governing lawful gambling and rules of the board and <br /> Bank Records Information agree, if licensed, to abide by those laws and rules, <br /> The board is authorized to inspect the bank records of the including amendments to them; <br /> gambling a=unt whenever necessary to fuifiil .any changes in application information wili be submitted <br />. requirements of c,urrent gambling ruies and law. to the board and local un~ of government w~hin 10 days <br /> Oath of the change; and <br /> I declare that .1 understand that failure to provide required information <br /> ., have read this application and all information submitted or providing false or misleading information may result in <br /> to the board is true, accurate and complete; the denial or revocation of the license. <br /> .all other required information has been fully disclosed; <br /> Signature of hief exe Date <br /> r <br /> <br /> 1. The c~y 'must sign this application if the gambling prem- 4. A coov of the local un~ of oovernment's resolution ao- <br /> orovina this aoolication must be attached to this aoolication <br /> ises is located w~hin city limits. . 5. If this application is denied by the local un~ of government, <br /> 2. The county "AND township" must sign this application if ~ should not be submitted to the Gambling Control Board. . <br /> the gambling premises is located w~hin a township. <br /> 3. The local unit government (city or county) must pass a Township: By signature below, the township acknowledges <br /> resolution specifically approving or denying this application. that the organization is applying for a premises permit within <br /> township limits. <br /> City' or County" Township" <br /> City or County Name Township Name <br /> Signature of person receiving application Signature of person receiving application <br /> I <br /> , <br /> I Date Received Title I Date Received I <br />. Title 1 <br /> Refer to the iristnJ~ns.for required attachments. j <br /> j <br /> Mail to: . . GambtfngControl Board <br /> Ros.ewood Plaza South, 3rd Aoor <br /> .'... 1711 W.County Road B lG214(Part 2) <br /> Ro.avllle; MN 55113 <br /> .::~- .- --- <br />