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Organiz�aton Name, <br />currenVpreviouz, Ucense number <br />currenVprevious exempt number <br />Street city state Zip e, County <br />A <br />Street City or Township State, Zip code County <br />MN <br />Date(s) of activity <br />Signature of person receiviin g application I Siginature of person receiving application <br />Ti +e Data received I T'ifle Data received <br />VMw I&Id <br />pift — Organktafm <br />YWIew — Omd rokims to Orgmnizalm ib <br />OwpWto ehaftd we" <br />GM — CAty or Couinly <br />M d <br />U. 0 t' o: <br />Department of Gaming - Garnbling Control Dii v,ision <br />M� ail Station 3,311 5 <br />St., Paul, MN 55,146-3315 <br />