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<br />~ <br />~HILLS <br /> <br />City of Arden Hills <br />1245 West Highway 96 <br />Arden Hills, Minnesota 55112 <br />Phone: 651.792.7800 <br />Fax: 651.634.5137 <br />www.cLarden-hills.mn.us <br /> <br /> <br />License No. GAM08- <br />Receipt No. <br />Amount Paid $150,00 <br />Date Recvd. <br />Ins. Cer!. <br />Tolal Fee Paid <br /> <br />2008 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 />~~ecQ~~c-lc6i I\'5S0C.lCL~6V\ <br /> <br />I PO. ~o:y-I:;<'()O 5<-[ kJau 'D;ll\~ I <br /> <br />~~--~~ Clo:(jk~ L'C~,_%~_\(n\[) ~\~~t--~~-~~-~~~ <br />__ffia_'<'fm Av-"x,..L(I-<;:,y_...... ..... <br />_~L{".?~Dmd3.~='::t=:z.]"J Business Fax: _(,,_$ i)mL,3L=:t"i(i1 <br /> <br />Business Name: <br /> <br />Property Address: <br /> <br />Nature of Business: <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />Federal ID#: <br /> <br />~~23 -~72'flt3i:Lk~~ <br /> <br />CO-<oc.i V\i\ to @ ,"'"., f\ . [(NY\ Website Address: <br /> <br />Ernail Address: <br /> <br />Premise Permit and Investigation Fee <br /> <br />$150.00 <br /> <br />*2007 Income and Loss Statement <br />.Projected 2008 Receipts/Prizes <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 fOf 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 no later than the <br />twentieth day of the month following the end of the quarterly period.) <br /> <br />A"O","'" ",_,"~., <br /> <br />r . ' <br />.'-~---~~ <br /> <br />Date <br /> <br />if;J;L1 t1g' <br /> <br />A-r p I ( ( ~0-u +e 0 fl~eXCL-\e- C~o.\C ; -\~ La.. 'Qi:LN\f'. VI \ ~ '^i;, oJ:: <br />~' \ell'. c::,~~" C-\\LV> <br />D\~ . '. . 10 <br />"f703 N \*,~Il\.uP-( <br /> <br />. . ').: 1+eL\.~ V\.CL'::> ~.'" <br />Lo..u I~\~"^-' ~~ T5 '{-ea.,,:'. T <br />~'N'-~\\~ .. <br />~" ~ t'CJ..~~ y. 'I ""u.'OS. <br /> <br />C-\r\O.y: ~\<l Lc <br />CCiV'gu. c...!-<. '-'::3 <br />. (\1\0. \NJ..u.e y- <br />\'\1lLJ-e- I()-<>e\{\ -+1ile. -.j <br />