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M0 <br />innesota L=ful Gambling <br />Irganization Li,cle�n,s,e Renewal Appl,i,catiioT� <br />1111-5- - - <br />Class of limnse Indicate in the 'class of Ilioewnses "box, Ow license dass that describes the types of <br />gamIblling your organization will be conducting* <br />Class A Pull-tabs. tipboar&. paiddlewheels, raffles,, bingo Class C - Bingo only <br />00070 K A, r-1-ftee M Do dL#t2$%& 6n�%nnMv ;vnielAmimhoole. rzifflar . ruarr. n . Ptaffiam mi <br />I <br />dI e f executive officer'., Street or P. 00 <br />l;7AQ T Arp Avjpni ip - <br />. 1iZA41JK4i is r- IS I FIVIVA <br />Last, Nww First Name Widde Name Maiden Tide Date of birth Day1ime phone number <br />Nelson,,__Daniel T 451 itleasurer 1�12) 698-2501 <br />6 When does the organization hold regular meetings? <br />Number at' Active Members ELIO-_ (must be age IS and older) Dlay of week 2nd Tbesday Time <br />gR. <br />ll dedare Wit: <br />• I hmm rmd this ap;Aication and all information submitted to <br />the, boart <br />jdj informt1binis true, a=rate and complete; <br />the ompensation, schedule is cuffenIt and on file with, ft <br />board* <br />Sidw inte,rnW conWs, are current and ion file with the board-, <br />all other reWfired information has been fully cisclosed; <br />I am the chief executve officer of ft orgardzation; <br />I assume full responsibility for the fair and lawful operation of <br />all acdvilties. to be, conducted; <br />I wiH farri'Wze myself W1 ith the laws, of PAnnesota govemIing <br />WwWl garnbling and rules of the board and agree, I licensed, <br />to abide by those laws and rulies, 'Including amendments to <br />thIem; <br />Signatur A" Chief E ti've I er Date <br />Mail with required attachIments to: <br />Gambling Control Board <br />Rosewood Plaza, South,, 3rd Floor <br />1711 W. County, Road B <br />Roseville. MN 55113 <br />