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<br />�WFAILW*i Department of Revenue, arning Division
<br />Mail Station 3,3115
<br />.99
<br />45_
<br />_"�t _2 St. Paul,, M�N', 55446-3315
<br />wl
<br />-5300
<br />V" (612)297
<br />GAMBLING LICENSE RENEWAL APPLICATION
<br />'1'
<br />For Board Use Only
<br />Paid Arent:
<br />Check No.
<br />Date:
<br />LICENSE NUMBER* 8-111111-611 1 EFF. DATE-.
<br />17 1111, 18 9�
<br />I AMOUNT OF FEE-..
<br />1. Applicant—Legal Name of Organization
<br />2. Street A,d�dre,ss
<br />VFV IPOST 7555 RHEUM
<br />1145 l4loodhill Or
<br />3. City,, State. Z,i�p,
<br />4., County
<br />5. Business Phone
<br />Roseville, NN 55113
<br />11 Ramsvv
<br />612 ) 493-5313
<br />6. Name, of Chief E,xe lutive Officer
<br />10,
<br />7. Business Pho.ne A;ee�529xy
<br />14a Z4
<br />612 21+
<br />A W/ 069-
<br />8. Name of Treasurer or Person Who Accounts for4evenues
<br />9. Business Phone
<br />X
<br />L 612
<br />10. Name,--of Gam,bl�ing Manager
<br />11. Bonds Number
<br />12. Business Phone
<br />Thoeas NcLaughlin %
<br />$3648767 - -
<br />--------
<br />(612 ) 571-4762
<br />13. Narne of Establishment Where, Gambling Will Take, Place
<br />14. County
<br />15. No. of Active Members
<br />VfW Post ISISS Ressv lls
<br />ass
<br />672
<br />16. Lessor Name
<br />17. Monthly Rent:
<br />New
<br />t $1
<br />1,8. If Bingo will be conducted with this license,, please specify days and times of Bingo.
<br />DRs Times
<br />Days
<br />'Times
<br />Ida s Times
<br />/V in, v
<br />19. Has, license ever been: 0 Revoked Date: 0 Suspended Date:, 0 Denied Date:
<br />20.,Have internal controls Ibeenl submitted previously" W-1yes 0 No (if uNo," attach copy)
<br />attach copy)
<br />2111., Has current, llea,se been filed with the board? //7 0 Yes"7" 0 No (it *No,
<br />9
<br />22. Has current sketch, been filed with the board? VY'es 0 No (if 'No," attach copy)
<br />GAMBLING SITE AUTHORIZATION
<br />By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any time, gambling is
<br />being conducted, to observe the gambling ands to enlfoirce the law for any unauthorized game or practice.
<br />BANK RECORDS AUTHORIZATION
<br />By my signature below,, the IBoalyd is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessary to
<br />fulfill requirements of current gambling r,ulles and law. OATH
<br />I hereby declare that:
<br />1. 1 have read this application and all information submitted to the Board:
<br />2. Alll information submitted is true, accurate and complete;
<br />3. All other, required information has been fully dliscloisedl; OW
<br />4, II am the chief executive officer of the organization;
<br />�5. 1 assume full responsibility for the fair and lawfull operation of all activities to be conducted;
<br />16. 1 wlill familiarize, myself with the laws, of the State, of Minnesota respecting gambling and rules of the board and agree, if licensed, to abide by those
<br />Names and"rulies,,, including amendments thereto.
<br />23. Off icia,i Legal Name of Organization Sig t e (Chief Executive Officer)
<br />I
<br />7
<br />V fLV 7rY�- WrPe—?Vu-
<br />. — I
<br />iffili 9 i-I a W*- T WY I'
<br />I hereby, acknowledge receipt of a copy of this application. By acknowledging receipt. I admit having been served with notice that this application will
<br />be reivilewed by the Charitable Gambling Control Board and if approved by the Board,, will become effective 60 days from the date of receipt (noted
<br />below),, 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 Board within 60 days of the below noted date.
<br />24. City/Cioun Narne (Local Ortwierning Body)
<br />Signature, of Plersion Aeceiving Application:
<br />Township: If site is located within a township, please complete items 24
<br />and 25:
<br />1 1 25,. Signature of Person Receiving Application
<br />Title Date RecVd date begins 60 day period)
<br />7r.
<br />i NLd
<br />Title:
<br />Name oil Person Delivering Application to Local Governing Body: Township Name
<br />CIG-000212-01 (418,91) W-h'i'le Copy —Board unary- - Applicant Pink—Local Governing Body
<br />
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