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I <br />M <br />LGI 230(2J28/90)) Minnesota Lawful GambWV <br />Application for One=Day <br />Off=Site Lawful Gambling <br />Send in this aWfication at least 610 days ibleforel your gambling activity. <br />Name of chiel executive officer (please print) <br />C!1 <br />H,arvev 6j.-,,)ecker <br />9 Imp <br />i N 'All <br />g <br />AL, <br />Narnel of lo off-site gam" r wAl be held <br />Roir,evl*iile Firp House # 1 lexi.nigton Ave. R o:z e. v1".1, I e M N 55113 <br />2 Addriess o1off-sile locallon City or township State Zip Codiel <br />I I <br />Ilexin6tion X I io sev * 11e 1121 55-1113 <br />41 <br />Octaber -7.-3090 <br />4, IHas your organization co'Adui6tfidlolf-site gambling this year? Yes 0 No - <br />,0 If yes, what was date of event? <br />Local Government Acknowledgement <br />lhave received a copy of this application. This application will be reviewed by the Gambling Control Board and will become offecbve 60 <br />dla�ys from the date of receipt by the city or county, unless the local government passes, a resolution to specifically forbid the activity. A copy <br />of that Iresollutlion must be received by the Gamblling Control Board within 60 idays of, the date filled in below. <br />luity or uounty (,to, t)le i,iiiieci in tor wt appucan <br />Ginty oricounty-nam, <br />T <br />Slignature of person receiving application <br />Title ' <br />�Sl A <br />i ownsnip <br />Township name <br />........... <br />Signature of person receiving application <br />Attach a copy of the lease for the off-site location <br />Mail this application and a copy of the lease to: <br />I Dl spar tent of Gaming - Gambling Control Division <br />Mail Sitation 3315 <br />St. Paul, MN 55146-l3315 <br />