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46. — <br />W200A, <br />Rev. (SV4190) <br />Minn tai Lawful Gambling <br />Oirgan License Application * Plaft 2 <br />ff <br />'Pum <br />io" 7. w . m;- <br />kc X. <br />M �.�i .ti ... sk.t,_., «'�:�r�'d�°� ...:'Pf' 51.,r.r.+.r�:+tiir:,.� .+�..�'t�s_Ys' 3'�r_....t....a.e'R . "°k:•ri ....... .�... r�"r.... _ S" ��s_+' ti,' �... ti*.°". ti,.... i��} �+�.�:1�"C+:� {w- '�•s.r�i.'i+[+a <br />Please Hist the lawful 10, puripose expenditures, for which Your organization will expend gam bling funds. (Refer to Minn. Statute <br />349.12 Subild.1 2.), Give specific examples. 'n <br />Saint Agnes Sc,hola,rsh# Fundo Saint Agnes Athlet*c Fund., Lions Cjjjb of <br />amel of organization's gambling. mianager CKY tate Zp Code <br />Robert, Ercolani 800 Dodd Road,, W. St. Paul 55107 <br />­, ... � ...- . . . . � .... W .................. ­.. � --- - - - - - - ---- - - - -- <br />air activities tnirougnwnm:h your organization rat ies funds,. <br />Tuition per student; Annual fund, drivel; special events da/ - <br />MMMMM� MINONNNOI� - nce auct J. on etc, <br />What percen�tage of your organization's funds are ralisedl for will be raised through lawful gambling? 5% <br />What" other activities does y,Qur organization engage in (nlot fuhdraising)? <br />al <br />Saint AMes is a Dr* ate. Cat'hol' �cwhQinl whnap- nr exigglance <br />I rd _imaT <br />leduc•l students grades kin dergar <br />ten, <br />V..... ..... <br />MIC <br />x <br />I e <br />WM: <br />I declare that: <br />oil, have read this application and all information submitted to the board; <br />*All information iisl true, accurate and complete; <br />*All other required information has been fully disclosed-, <br />el arn the chiiall executive officer of the organization; <br />*11 assume full responsibillity, for the fair and lawful operation of all activities to be conducted; <br />*11 w,illl familiarize myself with the laws of Minnesota governing llawfuul gambling and rules of the board and agree, if licensed, <br />to abide by those lawls, and rules, including amendments to therm, <br />*A, membership list of the organizaWn will be available within Seven days after it is requested by'the board; <br />*Any changes, inl apipfication information will be submitted to the board and local government within 10 days of the change; and <br />*A termination p�ia,n will be submAted to the board within 15 days of termination of all premise permit(s). <br />*I certify that the gambling manager is bonded and licensed as required per Minnesota Statute. <br />*Failiure to provide required information or providing If also or misleading information may result in the denial or revocation of the <br />license,., <br />Signature of Chief Executive Officer Date <br />Nil <br />Refer to the Instructlains for the required attachments. REMINDER: The- organization's chief executive officer and <br />treasurer must complete the O�rganizatlon Officer Aff Idavit, form LG, 200B. <br />Mail- to Department of Gaming - Gambling Control Division <br />Rosewood Plaza South�, 3rd Floor <br />17'11 W. Counity, Road B <br />Roseville, MNI 5511'3 <br />