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Reicard NIo.
<br />69I62
<br />dt%6&'U"
<br />Depariment of �Rev en�u�e Gaming Division
<br />W,
<br />Mail Station 3315
<br />NORTH. SU'BURBAN YOUTH ASSOC ROSEVILLE
<br />St. Paul, MN 515,1 15
<br />(612N 297�-530IO
<br />............
<br />For Board Use Only
<br />Paid Amt-
<br />Check No.
<br />Date:
<br />LICENSE NUMBER: B-111485-111151 EFF., DATE:
<br />16 /8118 9 AMOUNT OF FEE: 1125,10
<br />1. Applicant—Legal Name of Organization
<br />2. Street Address,
<br />NORTH. SU'BURBAN YOUTH ASSOC ROSEVILLE
<br />Box 13253
<br />31. City, State,, Zip
<br />4., County
<br />5. Business Phone
<br />losiville, IN 55113
<br />Ramsey
<br />612 40ol ?6 1111141 to 50*0
<br />6. Name of Chief Executive Officer
<br />7. Business Phone
<br />R Robert INiatson
<br />( 612 ) 633-1156
<br />8. Name of Treasurer for Person Who Accounts for Revenues
<br />9. Business Phone
<br />Jam trorlifick
<br />612 341-7126
<br />10. Name oil Gambling IMlaunager
<br />11. Bond Number
<br />12. Business Phone
<br />Betty Natsion
<br />RPS316933
<br />612 633-6156
<br />13. Name of Establishment Where Gambling Will Take Place
<br />14. Counity
<br />15. No. of Active Members
<br />loseville H011day Inn Rostvil,le
<br />Ramsey
<br />16,. Lessor Name
<br />17. Monthly Rent:
<br />hn Alloseville
<br />18. If Bil ng�o will be conducted with this Ililcernlse, please specify, days and times of Bingo.
<br />Times
<br />Cia s
<br />Times
<br />mays
<br />Times
<br />19. Has license ever, been: 0 Revoked Date: wow
<br />C1 Suspended Date: 0 Denied Date:
<br />e.
<br />201. Have, internal controls been submitted previously'?
<br />TKYes 0 No (1114No," attach copy)
<br />1. Has currenit lease been filed witJhl the board?
<br />0 Yes, 1!,91 No (if ii"No," attach copy)
<br />22. Has current sketch been filed with the board)?
<br />I 13 Yes K No (if "'No," attach copy)
<br />GAMBLING SITE AUTHORIZATION
<br />by my signature below, local law enforcement officer's or agents of the Board, are hereby authorized to enter upon the site, at any time, gambling is
<br />being conidulctied,, to observe the gambling laund to enforce the law for any unauthorized, giame or practice.
<br />BANK RECORDS AUTHORIZATION
<br />By my signature bellow, the Board is hereby authorized to inspect the bank records, lot the General Gambling Bank Account whenever necessary to
<br />f'ulfilll reqluire,me,nts of current gambling rules and law.,
<br />OATH
<br />I hereby declare that:
<br />1. I have read this application arndl all information submitted to the Board;
<br />211. All iinflormatioln, submitted is true, accurate and complete.:
<br />3. Al'll other required information has been fully disclosed*
<br />4. II tarn the chief' executive officer of the Iorganization ;
<br />S. I assume, full, responsibility for the, fair and lawful operation of all activities to, be conducted;
<br />6. 1 lwillll familiarize myself with thie, laws of the State of Miii nnesota respecting armlblliingl arndl rules of the board and agree, if licensed, to abide by those
<br />laws and rules, including amendment's 'thereto.
<br />23. Official Legal Name of Organization Signature (Chief Executive Officer) Date Title
<br />Y-,4,!sSCx_t wvrq�
<br />I hereby acknowledge Irecleilpt of a copy of this applilication., By acknowledging receipt, I admit hiaviinlg been served with notice that this application will
<br />be reviewed by the Charitable Gambling Control IBoardl and if approved by the Board, will become effective 60 days from the date of receipt (noted
<br />(bellow), unless a resolution of the local governing body is passed which specifically disallows such activity and a copy of that resolution is received by
<br />the Charitable, Gambling Control Bioiard within 60 days, of the below noted date.
<br />24. Ci vlCounty INal Local Governing Body) Township: If site is located within a township. please complete items 24
<br />I and 251:
<br />Signature of Person Flecei
<br />� let
<br />T e,-7 J:)a
<br />g Application:
<br />to Recelved (this date !r 60 day period)
<br />i1cm-
<br />came of Person Delivering Application to Local Governing Body:
<br />CG-00022-011 (4,189)
<br />251. Signature of' Person Receiving Application
<br />Title:
<br />Township Name
<br />White Copy—Board Canary —Applicant Pink—Local Governing Body
<br />
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