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<br />... ~, ...:.:: <br /> <br />e <br /> <br />- <br /> <br />-' <br /> <br />e <br /> <br />PagelC1t2 <br />Mlnne$otll Lawful Gambling 4100 I'ar e...,rd Uo. Only <br />Application to Conduct Annual Off-Site Gambling _ LG230 <br /> <br />Licensed Organization Information (ple_ print elllnfonnatlan) <br />Organization Name ('j /lciE ~IVS - U:XIIV{; 7lJ'>J ,L_.IIJVJ'f License Number (5 dIgits) .a // () t <br />License E>.piration Date (]~ I D,/ I b I Class of Organization License (A, e, C, 01' D) <br />Daytime Phone <br />Name of Chief Execufive OffICer (' HAl LE:J t.J kUA#.1 7""1./ WI~ Number ( 'J l. J )' <br />(DtJ not lI.t th. gambling man_g.r) <br /> <br /> <br />Gambling'Premls.. Information <br />Name of establishmenUlunclicn where gambling activity will be conducted /lVil I)/} 7' .:r,ufo.J <br /> <br /> <br />Street Address and City 0 .' <br />(D, not ..... . poet oflIce baK. It no It root odd....., write In the raid deolgn.lIon., Ex ; 3 miles ..ot of <br /> <br />Lease Requl...~ent. Does your organIzation own the gambling premises? <br /> <br />o II yes, no Ie... is required. <br /> <br />[2Sl11 no, a la.se agreement must be attached (you mllY use lease form LG224, evallable from the BOllrd). <br />However, no leaslIls required i1' Ihe only gambling activity to be conducted Is a raffle. <br /> <br />1/. <:;'5" II ).. <br />. 63 IIn County RaId 42) <br /> <br />Dele{S) for off../te actlvltyupto 12 consecutive days: <br />Begin dateC2.3.....JJ.LLi2L <br />End date O~3.L.J..tu... <br /> <br />Typa of Gambling Activity. Check the box(es) for the <br />gembling activity your organization will be' conducting. <br /> <br />o Pull-Tabs D Bingo [:::JTipboElld$ <br />~ Raffles D PaddJewheels <br /> <br />Local Unit of GovernmentAcknowledgment <br />If the gambling premises Is within city limits, the city must sign this sppllclltlon and provldl' s resolution. <br />On behalf of the city, I acknowfedgethat this P~ofcltyJR.tlf:l.J, )11\..'-S <br />application will be forwarded to the appropriate city <br />officials, the city must pass a resolution s!)eclflCally <br />approving or denying this ap!)lIcation, and a copy of tM/YvAP IL. t(JrMJ <br />the resolution will be forwarded to the applying (Signature of clly personrwi r8Cflivlng application) <br />organization. Tille Gll'f -rIll4-SI.i!Lt.'(ft Dale \ ,'1,01 <br />If tha gambling pl1lmlsu Is located In I township, both the county 8, township must sign thls s!)plh:ation. <br />The county must provide a resolution. <br />Forth. town.hID: On behalf of the tOlNnshlp, J <br />acknowledge that the organization Is epplying for Print name cf lownltlllp <br />Onlrday, off-site gambling activity within the tOlNnShip <br />limits. <br />A tOlNnshlp has no statutOI)' authority to approve or (Signature of township official acknowledging applic.tion) <br />deny an application (Minn. Stat. i 349.213, subd, 2). Title Date , , <br />For the county: On behalf of the county, I acknowl- <br />edge that Ihis application will be forwarded to the Print nlme at county <br />appropriate counly offICials, the county must pass a <br />resolution specifically approving or denying this (Signature of county peraannel receiving 'PPllcation) <br />application, and a copy of the resolution will be <br />forwarded to the applying organization, Till. Oate I I <br />Chief Executtve Officer (CEO) Acknowledgment and Oath <br />I have read this application. and all information is true, accurate, snd complete, I hereby authorize thEI Gambling <br />Control Board to modify the class of organization license to be consistent with the class of permit being applied fer. <br />CEO Signature Date I I <br /> <br />"OO~ <br /> <br />'~w~w S~ H1~IAaSOH <br /> <br />ZOISS~9IS9 xv~ ~S:~l craM IO/LI/IO <br />