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'""haritable G,ambling Control Board
<br />R -�475 Griggs-Midway B�l�d�g.
<br />�m N I
<br />1821 University Ave. • St. Paul,y MN 55104-33831
<br />0555
<br />1 _(61 2) 6142 -
<br />For Board Use Only
<br />Paid Amtd-
<br />Check No.
<br />Date.-
<br />GAMBLING LICENSE RENEWAL APPLICATION
<br />1 EFF'. DATE: AMOUNT OF FEE:
<br />LICENSE NUMBER: A -06693 -W 4. 11 4 46
<br />IN, Applicant—Legal Name of Organization
<br />2. Street, Address
<br />KNIGHTS, Of' COLUNBUS COUACH, 40,21 'ROSHILIF
<br />,—.5 North Sn 1.16 J n I
<br />3& City,, State,, ZIP
<br />4. County
<br />5. Business Phone
<br />Roseville XN 11
<br />)j31-2415
<br />61. Name of Chief Executive Officer
<br />7. Business Phone
<br />jtwx"Oay�x Leon F IS A,xtman
<br />612) `7 1,. 4P 54
<br />r
<br />V
<br />C)
<br />N
<br />8. Name of Treasurer or Person 'who) Accounts for Revenues
<br />9. 1 Business Phone
<br />IMM KWX Robert JV R!argo
<br />(612) 64KI-6240
<br />ME X)i.M. x K
<br />110. Name of Gambling If
<br />1 11. Bond Number
<br />12. Business Phone
<br />Arthur McCarthy
<br />I I f Xi'S 8 31019 31
<br />611 454-4668
<br />13. IName of Establishment Where Gambiling Will Take Place
<br />14., County
<br />15. No. of Active Members
<br />Of C 0,41,1 Roseville
<br />Ramsey
<br />rv. 5 1
<br />—1
<br />16. Lessor Name
<br />17. Monthly Rent:
<br />'Nazareth B11dq Assoc
<br />7J."M N12000
<br />18. If Bingo will be colnldulctedl with this license, please, specify days and times of Bingo.,
<br />Days Times
<br />D Times,
<br />Da s Times
<br />lliednensdav 0 P 01
<br />2:30-111* 0
<br />F r*day
<br />3�0_ 1,1 P 1
<br />a t iar,01 q. 0,
<br />19
<br />Sunda,y 1;00�31010 Lf,0141
<br />-.%undaY
<br />3 0 3 0 w- 51 3 0 P1
<br />unday
<br />30
<br />19. Has license ever been: 0 Revoked Date:
<br />5 =0
<br />Suspended Date: 1, 13 Denied Date:
<br />201. Have internal controls been submitted previously?
<br />)0 Yes 0 No (If "No," attach copy)
<br />211. Has current lease been filed with the board?
<br />)b Yes ❑ No (if "No," attach copy)
<br />22. Has current sketch been filed with the board? X71 Yes I No It "No*" attach copy)
<br />GAMBLING SITE AUTHORIZATION
<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. gam,blinng, is
<br />being, conducted, to observe the ga,m�bllin�g and to enforce the law for any unauthorized game or practice.
<br />I
<br />BANK RECORDS, AUTHORIZATION
<br />By my siglnatlure below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessAryio
<br />fullfilll requiirements of current gambling rules and (law.
<br />OATH
<br />II hereby declare that:
<br />1. I have, read this application and alll information submitted to the Board;
<br />2. All information sulblmitte+dl is trine, accurate and compllete;
<br />3. All othier Irequiired information has been fully disclosed;
<br />4. 1 am the chief executive officer of the, organization;
<br />5. 1 assume full Iresponsibiility for the fair and tawful operation of all activities to be coin�dulcte,d;
<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�., Offlicial sLegal Name of Organization Signature (Chief Executive Officier) Date Title
<br />K1 g
<br />,n,* hti of '"o 1 um. tus V0000,00, rand Kn ght
<br />ov,
<br />Nazareth Counc ill ,o�4,021
<br />I _-Z
<br />ACKNOWLEDGEMENT OF NOTICE BY ILODAL GOVERNING BODY
<br />I hereby acknowledgle receipt of a, copy of this appilicatioin. By acknowledging receipt, I admit having been served with notice that this application will
<br />be reviewed by the, Charitable Gambfing Control Board and if approved by the Board, will become effective jr-� ya from the date of receipt (noted
<br />below), unless a, resolution of the local governing body is passed which specifically disallows such activit anG_a�66py of that resolution is received by
<br />thie Charitable Gambling Control Board with!p,���ys, of the below noted date.
<br />. J, I/ "
<br />24., City /Count y Name (Local Governing Body)
<br />u,
<br />Si ig n at u r,e of Pe r,to on R e c e I iving Application:
<br />ti
<br />q
<br />Title Date Received (this date begins 3 ay period)
<br />Ty, "19A
<br />7
<br />ti
<br />Name o APerson DelivierA App,0qatio
<br />_qW Local) Governing Body:
<br />CG-000122-011 (51187)
<br />Township: If site is (located within a township, please complete items 24
<br />and 25,:
<br />25. Signature of Person Receiving Application
<br />1.
<br />Titl�e'.
<br />Township Name
<br />White Copy — Board
<br />Canary —Applicant Pink—Local Governing Body
<br />
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