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<br />~ <br />/f\~HILLS <br />. <br /> <br />City of Arden Hills <br />1245 West Highway 96 <br />Arden Hills, Minnesota 55112 <br />Phone: 651.634.5120 <br />Fax: 651.634.5137 <br />www.ci.arden-hills.mn.us <br /> <br /> <br />License No, <br />Receipt No. <br />Amount Paid <br />Date Recvd. <br />Ins, Cert. <br />Total Fee Paid <br /> <br />GAM05- <br /> <br />2005 Charitable Gambling Premise Permit- <br />Application Form <br /> <br /> <br />Information (allfields are required) <br /> <br />Business Name: <br /> <br />L "'_0 'i <br /> <br />Sl,..IPPel, CP.IH'r <br /> <br />A ~uJA <br /> <br />Property Address: <br /> <br />I <br /> <br />I <br /> <br />J :1 7"3vJ. C!-~"'~ f<o....J K A~ U#- <br /> <br />Nalure 01 Business: __'.__C!.~__~(.l.-o>..-':.:~--=-p.&Q -r-...G-, <br />~~_U_~_ <br />k$J.t.{fl~O'" ]:L <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />Business Fax : <br /> <br />e <br /> <br />Email Address: <br /> <br />Website Address: <br /> <br />Federal ID#: <br /> <br />-ILJiL-LI./Q/5"9(P <br /> <br />Premise Permit and Investigation Fee <br /> <br />$150.00 <br /> <br />'2004 Income and Loss Statement <br />'Projected 2005 Receipts/Prizes <br />'Copy olLease Agreement <br /> <br />(All organizations pennitted to conduct lawful gambling within the City of Arden Hills shall contribute 10% (ten percent) of their <br />net profits derived from gambling activities \vithin the City to a special fund to be administered by the City Council for lawful <br />purposes. Payments to the fund shall be calculated for quarterly periods ending on the last days of March, June, September and <br />December. Quarterly instaHment payments shaH be submitted together with vecifiable suppmling documentation not later tban <br />the twentieth day of the month following the end of the quarterly period.) <br /> <br />Authorized Signalu~ <br /> <br /> <br />Date 'i - .;lC)-O 55 <br /> <br />e <br />