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Department of Revienuie - Gaming Division MIail Station 3315 St. Paul,, MN 55146-3315 (6112), 2917'-5300 GAMBLING L,ICEN E RENEWAL APPLICATION For Board Use Only Paid Aml: Check No. Date: 6. Name of Chief Executive Officer 7.13usiness Phone R Robert Natson ( 612 ) 633-1156 8. Name of Treasurer or Person Who Accounts for Revenues 9. Business Phone James Crenick 612 $41-7126 10. Name, of Gambling Manager 11. Bond Number 12. Business Phone Betty Natslon RPIS'316933 ( 612 ) 633-4155 13., Name of Establishment Where Gambling Will Take Pilace 14. County = 15. No. of Active Members Chip Stick Inn Rosey! I I e Ra�ms�ely 251 16., Lessor Name 17. Monthly Rent: Food World Inc 18., If' Bingo will be conducted with this license, please specify days, and 'tunes of Binigo. taus Times Times Da S Times 19., Has license ever, been: C] Revoked Date: 0 Suspended Date: El Denied Date: 20. Have intiernal controls, been submitted previously? X'Yes F7 No (It "No," attach copy) 2111. Has current lease been tiled with the board?' Ll 'Yes S No (If' "No," attach copy) 2121. H' as current sketch been filed with the board? %Yes C3 No (if "No," attach copy) GAMBLING SITE AUTHORIZATION By my signature Ibelow,, local law, enforcement', officers, or agents of the Board are hereby authorized to enter upon the site, at any time, gambling is Ibeirngi conducted, to observe the igambl�inig ands to enforce the law for any unauthorized game or practice. BANK RECORDS AU�THO,RIZAT'ION By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessary to fulfill requirements of current gambling rules andl law. OATH I hereby declare that.- 1 . I have read this application and allll information submitted to the Board; 2. All information submitted is true, accurate, and complete; 3. All other required information has been fully disclosed; 4. 1 am the chief executive officer, lot' the organization; 5. II assume full responsibility for thie fair and lawful operation , of all activities to be conducted; �6. 1 will) faumnillia:rize myself with the laws of the State of Minnesota respecting gambling and rules of the board and agree, if licensed, to abide by those laws and rules, including amendments thereto, 213. Official Legal Name of Organization is Z E 1: Itlecu 1 tive Officer) Daitile r - Iff NE&% ACKNOWILEDGEMENTOF NOTICE BY'LOCAL GOVERNING BODY I (hereby acknowledge receipt of a copy of this application. By, acknowledging receipt, I admit having been served with notice that this application will be reviewed by the Charitable Gambling Control B'oardl andl iif approved by the Board, will become effective 60 days from the date of receipt (noted below), unless a resolution of the local governing body is passed which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 days of the below noted date. 24. City/County, Name ocaul Governing Signature of Person Receiving Application: 6womENI' 4 Date Received (this date begins 60 day period) Township: It site is located within a township, please complete items 24 and 25" 25. Signature of Person Receiving Application Title: Name, of Person Delive'ring Application 110 Local Governing Body: I Township Name, GG-00022-011 (41'891) White Copy—Board Caen arvi —Applicant Pink—Local Governing Body