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Minnesota Lawful Gambling Application to Conduct One-Day Off-Site Gambling - LG230 Licensed Organization Information (please print all information) Organization Name C IILc ifF fiNEr - Le:;Cl/vG. 7lrrJ LlOIi:IcCnseNumber(5di9ilsl (!) 1/ D " License Expiration Date I I Class of Organization License (A, B, C, or 0) -It ^ .A . Daytime Phone NameofChiefExecutiveOfficer----L) () /'UI JIft1 w1f7 11!: Number! ) (Do not list the gambling manager) Gambling Premises Information Name of establishment where gambling activity will be conducted . : , I If For Board Use Onlv e x Street Address and City Co. " E. /JiltJ(;?v tt.J I/. (00 not use a post office box. If no street address, write in the road designations. Example: 3 miles easl of Hwy. 63 n County Road 42) Does your organization own the gambling premises? D If yes, no lease is required. ~ If no, a lease agreement must be attached (you may use lease form LG224, available from the Board). However, no lease is required lithe only gambling activity to be conducted is a raffle. Date of one-day off-site activity: 'I I--L!l.-J q'i If you are conducting a raffle, enter the date of the raffle drawing. The gambling activity conducted on this day may not exceed 12 hours. ' Local Unit of Government Acknowledgment . . Check the box(es) which indicate(s) the type of gambling activity your orgllnization will be conducting for this one-day off-site activity. D Bingo D Paddlewheels D Pulnabs ISaRaffles D Tipboards NOTE - You may only conduct activity authorized by the class of your organization license. On behalf of the city, I acknowledge that this application will be forwarded to the appropriate city officials, the city must pass a resolution specifically approving or denying this application, and a copy of the resolution will be forwarded to the applying organization. For the townshio' On behalf of the township, I acknowledge that the organization is applying for one-day, off.site gambling activity within the township limits. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). For the county: On behalf of the county, I acknowledge that this application will be forwarded to the appropriate county officials, the county must pass a resolution specifically approving or denying this application, and a copy of the resolution will be forwarded to the applying organization. Print name of city e (Signature of city personnel receiving application) Title Date I I Print name of township (Signature of townShip official acknowledging application) Title Date I I Print name of county (Signature of county personnei receiving application) Title Date I I Chief Executive Officer CEO Oath I have read this application, and all information is true, accurate, and complete. r CEO Si nature / Submit this application at least 30 d s prior to the date of your scheduled activity. Attach the resolution of approval from the local unit of government and a copy of the lease agreement, if required. Mail to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113 Date / ,,ps-, 9'1 Questions on this form should be directed to your licensing specialist atthe Board at (651) 639-4000. Hearing impaired individuals using a TTY maycallthe Minnesota Relay Serviceat 1-8Q0.627 -3529aOO ask to place a callto (651) 639-4000. Thispubilcation will be made available .. in alternative format (Le.large print, Braille) upon request. .. The information requested on this form will become publiC information when received by the Board, and will be used to determine your compliance with Minnesota statutes and rules goveming lawful 9ambling activities. 7/98