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<br /> <br />License No. <br />Receipt No. <br />Amount Paid <br />Date Recvd. <br />Ins. Cert. <br />Total Fee Paid <br /> <br />GAM06- G~ <br /> <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 />$100.00 <br />-- lS ,,4- <br /> <br />/oo.eiD <br /> <br />2006 Charitable Gambling Premise Permit- <br /> <br />Application Form <br />(Terms of the License: 2 Year Agreement) <br /> <br /> <br />Information (all fields are required) <br /> <br />Business Name: <br /> <br />,Iii <br />I <br />I T77(.& (C'd/I,e)/::;- <br />Il,r;;,ft, H /l J j", /H.IV .serf! Z <br /> <br />_.c.d;;JYL';I:d>1__-62'",dJ/.r ?Zf- <br /> <br />V~cc"'eu. .Jd'c'.5.JL(~}LA__._ <br /> <br />...f.l:.L..( J .1__(3_lc'i __ <br /> <br />;; <br />v <br /> <br />6{),il- SA-- Kc...~<.'~~ l.A-'-<c-~~J-..-.... <br /> <br />Property Address: <br /> <br />I <br /> <br />Nature of Business: <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />Business Fax: <br /> <br />Email Address: <br /> <br />Website Address: <br /> <br />. <br /> <br />Federal 10#: <br /> <br />_i-.lLl '1 {SJ8:f__ <br /> <br />Premise Permit and Investigation Fee <br /> <br />$100.00 <br /> <br />*2005 Income and Loss Statement <br />'Projected 2006 Receipts/Prizes <br />'Copy of Lease Agreement <br /> <br />(All organizlltions permitted to conduct la'.vful gambling within the City of Arden Hills shaH contribute 10% (ten percent) of their <br />net profits derived from gambling activities within the City to Q special fund to be administered by the City Council for lawful <br />purposes. Payments to the fund shall be calculated for quarterly periods ending un the last days of March, June, September and <br />December. Quarterly installment payTIlentE sh::!!] be submitt-:;:d togctl-:.er "i:ith \'trifiable sUPPorTing documentation no later than the <br />t\ventieth day of the month following the end ofthc quarterly period.) <br /> <br />Authorized Signature <br /> <br /> <br />Date <br /> <br />,;';6]Ai <br /> <br />. <br />