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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 />License No. <br />Receipt No. <br />Amount Paid <br />Date Recvd. <br />Ins. Cert <br />Total Fee Paid ib I CO. OJ <br /> <br /> <br />2006 Charitable Gambling Premise Permit- <br /> <br />Application Form <br />(Terms of the License: 2 Year Agreement) <br /> <br /> <br />Information (allfie/ds are required) <br /> <br />Business Name: <br /> <br />mlA <br /> <br />. <br /> <br />i~nll <br /> <br />31'1~ COn{)~lI'j/1llc, <br /> <br />Nature OfBusiness:EL\I}~o~t._t}A .LLiahs_____ ..__~_ <br />SUS~.:DEokcs"", ,_._ <br />t.d21::S<t3-'J3SLc2 <br />Email Address Sy~~~'?it\OcdJt)\e:;LlQS.O:-,>n Websi!e Address: <br />,ZfL;.:-,3'2M'[jL222=:"_ <br /> <br />Property Address: <br /> <br />A-rr}~ k~ QI s m VI 5131/ 'do <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />Business Fax: <br /> <br />Federal ID#: <br /> <br />Premise Permit and Investigation Fee <br /> <br />*2005 Income and Loss Statement <br />'Projected 2006 Receipts/Prizes <br />*Copy of Lease Agreement <br /> <br />...!ftQD. i.:X <br /> <br />v'" <br />../" <br />./ <br /> <br />(All organizations permitted to conduct lawful gambling \vithin the City of Arden Hills shall contribute] 0% (ten percent) of their <br />TIel profits derived from gambling activities within the City to a special fund to be administered by the City Council for lawful <br />putVoses. 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 supporting documentation not later than <br />the t\vcnticth day of the month following the end of the quarterly period.) <br /> <br />Authorized Signature(~~,~ <br /> <br />Datc)=!fc.-:l), ~ <br /> <br />. <br />