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<br />%- <br />~~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 />GAM06-00i <br />Jd30 <br />1& roc,CO <br />100ft} <br />-[bJ ()()-~ ' <br /> <br />License No, <br />Receipt No. <br />Amount Paid <br />Date Recvd. <br />Ins. CerL <br />Total Fee Paid <br /> <br />2006 Charitable Gambling Premise Permit- <br /> <br />Application Form <br />(Terms of the License: 2 Year Agreement) <br /> <br /> <br />Information (allfields are required) <br /> <br />':i 1 0 200S <br /> <br />t1inY\esot~ ~vesdL'Y)gJI/;1(, <br /> <br />lL~ 2 d.. Ei>'le:~o", AvQ.. (0, VY\rl) tnl\I <br />M_.___~Ldb ..,5f10.v-ts, <br />~V\ Chc..\'1.~I~__._ <br />. (; J ~,8~~_Q%j.~1 <br /> <br />Business Name: <br /> <br />Property Address: <br /> <br />Nature of Business: <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />EmailAddress: mO!AS(iWdc@c;f-lI,,,,k, CO...... <br /> <br />. <br /> <br />Federal ID#: <br /> <br />t.ll-L;).I:J..~L~X__M__ <br /> <br />Premise Permit and Investigation Fee <br /> <br />'l/O.eO <br /> <br />L_S~~_~~_n__._~_ -- ~~~~,~~~~ <br /> <br />ss~ <br /> <br />Business Fax: &,I?::_~_d;) <br /> <br />1030 <br /> <br />Websitc Address mnt.lS"-(..<J(!:sJ/;",'J .Q.,:, <br /> <br />*700"i,Tnr.ome ano_J oss.Sfatcment__ /' ~..~~.__~~ <br />'Projected 2006 Receipts/Prizes J/,"'~peii:>. DCJ <br />*Copy of Lease Agreement ~ <br /> <br />(All organizations permitted to conduct lawful gambling within the City of Arden Hills shall contribute 10% (ten percent) of their <br />net profits derived from gambling activities within 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 installment payments shall be submitted together with verifiable SUpportlllg documentation not (ater than <br />the t\ventieth day of the month following the end oftne qual1erly period.) <br /> <br />Authorized Signature. <br /> <br />WJL <br /> <br />. <br /> <br />Date! 2- 1../ - d-av';- <br />