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Minnesota Lawful Gambling Premise Permit Application - Part 2 of 2 Gaffii)i1rtg:iBaft~;;A@&jUJit~iTfird~mflmtmfi:I~~ill~J\:\\lliI@l:~fi~1[t:iil\f*~[fl.t.fl~i:lt;I::i.~i::\~~l::\r;~:M~~)tiJ:[~::::~:~)t:\::l~[li::~\:::l:::i:\\:\:\:~:\\\\;~\t~\~~t~\\:~\:\:;~:~~:::;:::l;;:li.I:\l:;: Bank Name ", ,'. _'" .. . ' '. Bank Acccunt Number -(I c. GPv-;-z ~Y' .l3C-C:';1 ~ '3 &> - / / B Z/ Bank Address / City State Zip Code / 'S-O .5 .L-t~.f~ frr-&1i;,r .L'v{c H~ .. 5~~.~~.......... L ",- / /t;.'C8o ~~ G ~ /?;. <;t: r /C.- ~ · ~ ~ ,......$.:'""..'-- )? '" Co IV ri:v~ r ./ -{ ..,. · , _ " ~ ? ,1./. ~ ~€iIJ1I' $1- 0 _. ~ C(t;"lIcr~...-z-- ~/~ /1/ J'$/~F- ~~/e. /1:"',</ 550<:3 v: /'. . /' / / /c~/P ZI/e?6-I-"t/ S-{ ......~h~.c..-s C'-'""-- -S~"../..~ H~ S5C/I,J C~O - Pc".;x,.~--c-:r Prcv.(~ JO~ oGmblii1'g'Slie Authorization -I am the chief executive officar of the!organization; I hereby consent that local law enforcement officers, the -I assume full responsibility for the fair and lawful opera- board or agents of the board, or the commissioner of tion of all activities to be conducted; revenue or public safety, or agents of the commissioners, _I will familiarize myself with the laws of Minnesota may enter the premises to enforce the law. governing lawful gambling and rules of the board and Bank Records IIiformat.1oD agree, if licensed, to abide by those laws and rules, The board is authorized to inspect the bank records of the including amendments to them; gambling account whenever necessary to futfill -any ,changes in application information will be submittsd requirements of current gambling rules and law. to the board and local unit of government within 10 days Oath of the change; and I declare that: .1 understand that failure to provide required information ., have read this application and all information submitted or providing false or misleading information may result in to the board is true, accurate and complete; the denial or revocation of the license. -all other required information has been fully disclosed; o nat e of chi xecutive offic Date I IIJ~/ 4. A CODY of the local un" of aovernment's resolution ao- orovinc this aoolication must be attached to this aoolication. 5. If this application is denied by the local unit of government, it should not be submitted to the Gambling Control Board. 1. The city -must sign this application if the gambling prem- ises is located within city limits. 2. The county .-AND township.. must sign this application if the gambling premises is located within a township. 3. The local unit government (city or county) must pass a resolution specifically approving or denying this application. Township: By signature below, the township acknowledges that the organization is applying for a premises permit within township limits. Townshl .- Township Name Signature of person receiving application I ~~. RecaiveQ J fUf ClfJ1/)/fu f; TIDe Date Received Refer to the instnJdions for required attachments. Mail to: Gambling Control Board ROMWood Piau South, 3rd Floor 1711 W. County Road B Rosevl1le. UN 55113 LG214(Par1 2) (R....7f2C.W 1)