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<br />-- <br /> <br />. <br /> <br />- <br /> <br />Minnesota Lawful Gambling <br />For Board Use Only <br />Application to Conduct One-Day Off-Site Gambling - LG230 <br /> <br />Licensed Organization Information (please print all infonnatlon) <br />Organization Name r!/tZ.C.Lt! fJiVE[":'LI::.'II/l1c'7>>V L/{/YIJ.f License Number (5 digits) ~)//Ot" <br />License Expiration Date 1k/6. / '"S / / 2{)Q/ Class of Organization License (A, B, C, or D) <br />Daytime Phone <br />Name of Chief Executive Officer V I (L C. I N J A J-I.t= (T F k / N h Number ( to) k <br />(Do not list the gambling manager) <br /> <br /> <br />Gambling Premises Information <br />Name ofestablishment where . . Jth _ ""'" <br />gambling activity will be conducted /If}{/ IJU,7 .-INtU .rr. f'/.h4t <br /> <br />Street Address and City 1 U) Efr ttf I. <br />(Do not use a post ollice box. If no streelacldress. write in lhe road designati ns. Example: 3 miles easl Hwy. 63 on County Road 42) <br />Does your organization own the gambling premises? Type of Gambling Activity. Check the box(es) which <br />D if yes no lease is required. in~icate(s) the type of g<!mbling activity ~our olJl~nization <br />~ ' ,,,,II be condw~t'ng for tIllS one-day off-site actMt';. <br />~ If no, a lease agreement must ~e attached (you D Bingo D Paddlewheels <br />may use lease form LG224, available from the D P II-Tabs D 1i board <br />Board). However, no lease is required ifthe only J2:g ~fIIes Ip s <br />gambling activity to be conducted is a raffle. <br />NOTE - You may only conduct activity authorized by the <br />class of your 0 anization license. <br /> <br />Date of one-day off-site activity: Mf!JJ.LD~ If you are conducting a raffle, enter the date of the raffle <br />drawing. The gambling activity conducted on this day may not exceed 12 hours. <br /> <br /> <br />Local Unit of Government Acknowledgment <br />if the gambling premises is within city limits, the city must sign this application. <br />On behalf of the city, I acknowledge that this Print nerr ~ of city C, T'f of ..!J!Yl:.W LuLU <br />application will be forwarded to the appropriate city <br />officials, the city must pass a resolution A.. A, (.2 J.-, , <br />specifically approving or denying this 7 <br />application, and a copy of the resolution will be (Signature of city personnel rel:eiving application) <br />forwarded to the applying organization. Tnle o 'j'f ~1l$4Iit.YL Date 1.. /"7 ,0:) <br />If the gambling premises Is located in a township, both the county & township must sign this application. <br />For the township: On behalf of the township, I <br />acknowledge that the organization is applying for Print name of township <br />one-day, off-site gambling activity within the township <br />limits. <br />A township has no statutory authority to approve or (Signature oflownship ollicial acknowledging application) <br />deny an application (Minn. Stat. ~ 349.213, subd. 2). Title Dale / , <br />For the county: On behalf of the county, I acknowl- Prinl name of county <br />edge that this application will be forwarded to the <br />appropriate county officials, the county must pass a <br />lBSoJution specifically approving or denying this (Signature of county personnel receiving application) <br />application, and a copy of the resolution will be <br />forwarded to the applying organization. Tille Date / / <br /> <br />Chief Executive Officer (CEO) Oath <br />:t;:~~iS. a~Plicat~UJatiOn is true, accurate, and complete. <br /> <br />CEOSign~ . <br /> <br />Date / /25' lao <br />Page 1 of2 <br />10199 <br />