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L, 0 1 GRE DAY OFF—SIr"It: <br />Re t-.u-;m to Charit-al lie Gambl, Ing Control Board 1 <br />1821 Univers.11,V%lo, Avenue — Rjn 75 LATH EM G.Ai -MLR?G APPLICIt.TION <br />St. Paul, 1N- 55104-3383 <br />Phorir-!: - 612/0"42-0555 <br />* A 111c enn s, e d o r V, car. i z a, t, 31.on, may, upon approval of t,hic.; ca-Tplication, conduct garbling on a <br />1 <br />PrET-Iisesi o,--'h ca is than Lciensed site one day per cal,endar year for not nore than 12. hours. <br />* If there are fewer thcazn 60 days between the date that the cit► /county siorns the <br />application and the date of the off -site gambling, include a x�-ai'Nrer from the. city/county <br />waivinqr-y, it 6101-da-7 dii,sapproval period. <br />Prin+&--, cl,2,arly or ty-iii Attach a copy of ths I-exase for them off•siite prsezili. CS e S <br />a After review, the appilLciatilon x,;111 be returned, to the organization with approval or <br />denial indicated, below'. <br />Oirganii zati" on <br />No �EUUA-A; -Y,IQCC <br />lr -ree P <br />t or '.0. box number) <br />Addess ( st <br />P. C)i <br />Cil ter <br />RV� k [ If tw <br />1hr % License No. <br />47-M V Pi Code <br />M-a- <br />iMR41-011V # (AN <br />Has yolu,r orgainizin't-ion canducted off-site gartibling this year � YES 0 rLo <br />State Zip Code <br />If YES, give date of event <br />S. IAtaO P. It. -rose for t1to one lay aff—flLe laofll --.51I' ngq <br />cer (please Pint) g; 12 lL L; -I F,* <br />■ Name o' f chilef executi v, lel- o f f'i P <br />OF C/ <br />MICT.ITPUTIMG P-ODY <br />OF ROTIU;1:1 Di %6A A. <br />sr <br />I herpby act.nowledge having been served with notice that this applica"Lion will be revievied by the. Charitable <br />Giom1bli-Ing Control board and, if approlvield, will bocoma.,% effective 60 drys from the dcite of reccipt <br />(notao'i be] lot-1), unl ess a resolutio�ri of the local governing body, is pz;ised that specifically disallows such <br />activit.-- yi and ai CODY Of U-1011-- resolution is received by the Charitable Gambling Control Eoard within 60 6ays of <br />the belorf noted (L'I'late. The city or county mray choose to waivic thex 60-day 6ckhowleduament.: periL-a by resolutiiii <br />Attach the viritten wai%,er to this request. <br />7. NaLm-C Of city o clountyl (local gioverning bodyl <br />rn ion t I c Date received <br />tuire �f �Rerson„ �recei vi ng alppl i cat' T4 i <br />i f si te i 5 loC.. i thin a <br />1-:arne of to,.,nZhip <br />C -,-Jinship, items 9 and 10 iniust be co:riplc-ted in i;d iii l.-ion to the county signature. <br />10. 5i cnature, () t pi <br />1 �--son i rcei One appl icat i on <br />I-101 r...Xald)i t <br />r- <br />/.pproved Ll D e n ic d <br />Executive Secretary Datc <br />M-tritable Gi.- mb 1.1*--ri a Control Board <br />L c *r r <br />