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<br />• Department of Revenue - Ga,ming DIivision
<br />For Board Use Only
<br />Mail Statim 3315 T,
<br />Paid Amt:
<br />St. Paul, MN 55146-33151
<br />Check No.
<br />(612) �297-51300
<br />Date:
<br />GAMBLING LICENSE RENEWAL APPLICATION
<br />IV
<br />LICENSE NUMBER,-., 8-11113-ti l I EFF., DATE:
<br />AMOUNT OF FEE® 1 "LIS . 6 0
<br />I. Applicant—Legal Name oflOrganization
<br />2. Street Address
<br />iANERICAN U610M FOST 542' ROSEVII.If
<br />710 W 01 po C
<br />3. City, State, Zip
<br />4. Coiu,nity
<br />5. Business Phone
<br />Rieseville, NN' $51,13
<br />Ramey
<br />( 612 ) 403-353.
<br />6. Name of Chief Executive Officer,
<br />7- Business Phone
<br />- III es 411 r A �-"xwA islie rl
<br />(619) 14n.35II
<br />8. INlame of Treasurer or Person, Whig Accounts for Revenues
<br />9. Business Phone
<br />Anat Aarie' Elde
<br />f 612 ) 483-3535
<br />110. Name of Gambling Manager
<br />11. Bond Number
<br />12. Business Phone
<br />John Kr It
<br />612 ) 483 -3535
<br />13. Name of Establishment Where Gambling Will Take Place
<br />14,. County
<br />15. No. of Active Members
<br />Aim Legion Plost 542 Rioseviffle
<br />hasey
<br />811
<br />16. Lessor Name
<br />17. Monthly Rent:
<br />18. If Bingo will be conducted with this l�icenisel, please specify days and times of Biingo.,
<br />D�ys Times I Times Dqy Times
<br />19. Has license ever been: 0, Revoked Date: ❑ Suspended Date: 0 Denied Date:
<br />20. Have internal controls. been submitted previously? JOYes 0 No (If "No,, attach copy)
<br />21 - Has current lease, been filled Iwilth the board,? n &L 0 Yes 0 No (it "No, attach copy)
<br />22. Has current sketch been filed with the board)? n a C] Yes 0 No (it -No," attach copy)
<br />mulmimimiul II
<br />GAMBLING SITE AUTHOR( ZATION
<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 land to enforce the law for any ulnauthoril zed game, or practice,
<br />BANK RECORDS AUTHORIZATION
<br />By my, signature bielow,F the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessary to
<br />fulfill requirements, of current gambling rules and law.,
<br />OATH
<br />III hereby, declare that:
<br />1. 1 have read thlis application and alll information submitted to the Board;
<br />2. All information submitted is true, accurate and complete;
<br />3. All other required information has been fully discloseld;
<br />4® 1 am the chief executive officer of they organization;
<br />5,. 1 assume full responsibility for, the fair and lawful operation of all activities, to be conducted,-,
<br />6. 1 will 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 />laws and rules,, including amendments, thereto.,
<br />23. Off icial Legal Name of Organization Signature (Chief Executive Officer) Date Title
<br />The Aw A c on W&Wey q
<br />C103 I Co der
<br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I Ihlereby acknowledge receipt, of a copy of this application. By acknowledging receipt, II admit haviing been served with notice that this application will
<br />bel reviewed by the Charitable Gambling Controt Board and if approved bythe Board, will become effective 60 days from the date of receipt (noted
<br />(below). un,less 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 Cotnitroll Board within 60 days of the below noted date.
<br />24., CitylCounty Warne (Local Golver Y)i Township-. It site is located within a township, please complete items 24
<br />I I =)] I L vrow I and 25,:
<br />Signature of Person Recelvin� Application:
<br />I .0l 9:r,
<br />Title,
<br />P
<br />Date Received I'this date blegilnls 60, day period)
<br />(Mare of Perko ?, Delivering Appitcatillon to Local Governing Body.
<br />CG-000212-01 (4/891)
<br />Title:
<br />T'ow�nlship, Name
<br />White Coply —,Board Canary- Applicant Pink Local Governing Body
<br />I
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