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<br />~ <br />~HlLLS <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.ci.arden-hills.mn.us <br /> <br /> <br />License No. GAMOB- () <br />Receipt No. <br />Amount Paid $150.00 <br />Date Recvd. <br />Ins. Celt. <br />Total Fee Paid <br /> <br />2008 Charitable Gambling Premise Permit- <br /> <br />Application Form <br />(Terms of the License: 2 Year Agreement) <br /> <br /> <br /> <br />Information (allfields are required) <br /> <br />Business Name: <br /> <br />rod-I mUIl~bY-J <br /> <br />IBox 1~d6'=>'6" J VJf...? B0.:'Jh-Im. ()'\t'\ LZfS It;;l, I <br />_D ~.S3~J:\-a ~~'S:_~~..k?.ILY\:L_.___.____.___. ..__..........__ <br />~-$-~.1)~1Ecs____. <br />.tQ 51::1_ ~:235b__. Business Fax(Q21-=Y~I=~ I ~Q <br />sJrk~ &YloYJ(.:k:'Cl~S. ~~Address: h~ldb;,lndxb~"Q~ <br />3j:"-~-'1ls.BS <br /> <br />Property Address: <br /> <br />Nature of Business: <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />Email Addres~: <br /> <br />F ederallD#: <br /> <br />Premise Permit and Investigation Fee <br /> <br />$150.00 <br /> <br />Please submit the foUowinl! forms with your application: <br />*2007 Income and Loss Statement <br />*Projected 2008 Receipts/Prizes <br />*Form LG200B Organization Officers Affidavit <br />*FolTIl LG214 Premise Permit Application <br />*Form LG200R A preprinted renewal from the Gambling Control Board (if this is a renewal) <br />*Fonn LG215 Lease for Lawful Gambling Activity <br />*Copy of Lease Agreement <br />*Insurance certificate <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 within the City to a special fund to be administered by the City Council for lawful <br />purposes. Payments to the fund shaH he calculated for quarterly periods ending on the last days of March, June, September and <br />December. Quarterly installment payments shall be submitted togelher with verifiable supporting documentation no later than the <br />twentieth day of the month following the end of the quarterly period.) <br /> <br />Anthorized Signature 3 l~ ~~ <br /> <br />Dale 5-ld- 0 8 <br />