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<br />MINNESOTA DEPARTMENT OF REVENUt
<br />�6a GAMING DIVISION For Board Use Only
<br />Mail Stlation 33'15 Paid Amt:
<br />Plaul IMF 55146-3315
<br />Check No
<br />Date:
<br />i I it
<br />LICENSE NUMBER: 8-60111-0011 11 E,FF. DATE:
<br />17'1 a 118 -0 1 AMOUNT OF FEE: sse.V
<br />1. Applicant—Legal Name of Organization,
<br />2. Street Address
<br />VFW POST 7555 ROSEVILLE
<br />141415 Woodhill Drive
<br />3. City, State,, ZIP,
<br />4. County
<br />5. Business Phone
<br />Roseville, All 551,1,3
<br />R,amisely
<br />4835313
<br />6. Name of Chief Executive, Officer
<br />T. Business Phone
<br />iH le n r Y, Robotnik
<br />(41g- ) 1,3
<br />8. Name of Treasurer or Person Who Accounts for Revenues
<br />9. Business Phone
<br />William Davis
<br />( 612 ) 426-3901
<br />10. Name of Garribling Manager
<br />11. Blond Number
<br />12. Business Phone
<br />Thomas 6 Xclauqhlin
<br />53648767
<br />512 571-0702
<br />113. Name of Establishment Where Gambling WIll Take Pilace
<br />14. County
<br />15. No. of Active Members
<br />VFW Post, 755,51
<br />Ramey
<br />A=
<br />161. Lessor Name
<br />17. Monthly Rent:
<br />$0
<br />18. If IBiingol will be c�onduc�teld with thiis, license, please specify days and times of Bingo.
<br />Da y s Times Gas Times Times
<br />SJA
<br />ff;�IUZ
<br />191. Has license ever been*. 0 Revoked D�ate-i 11 Suspended Date: E3 Denied Date:
<br />%L .
<br />20. Have internal controls been submitted previously? X Yes El No (if "No," attach copy)
<br />1. Has current lease, been filed with the board? A/W 0 Yes 0 No If uNo, it attach copy)
<br />22. Has current sketch eenl filed with the board? E3 'yes 0 Ni o (if ",No," attach copy)
<br />GAMBLING SITE AUTHORIZATION
<br />By my signature below, local law enforcement officer's 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 and to enforce the law for any unauthorized game or practice.
<br />BANK RECORDS AUTHORIZATION
<br />By my signature below, the Board Is hlereby iauth�orrized to ilnspect the bank, records of the General Gambling Bank Account whenever necessary to
<br />fulfill requirements of current gambling rules and, law.
<br />OATH
<br />I hereby declare that.4
<br />1. 1 have read this application and all information submitted to the Board;
<br />2. All, information submitted is true, accurate and complete;
<br />3. All other required information has belen fully disclosed;
<br />4. 1 am the chief executive, officer of the organization;
<br />5. 1 assume, full r,espoinlsiblillity for the fair and lawful operatilon 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, inctuding amendments thereto.
<br />23,. Official Legal Name of Organization I Signature (Chief Executive fficer) I Title
<br />ca/:-4.3 /049
<br />Vol a,
<br />7,
<br />,AC'KNOW'LEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I (hereby acknowledge receiipt of a copy of' this application. By acknowledging receipt, I admit h�aving, been served with notice that this application will
<br />be revilewleid by the Charitable Gambling Control Board and if approved by the Board,, will become eftective.,W'dc�ys from the date of receipt (noted
<br />below),, unless a resolution of the loos) governing body is, passed which specifically disallows such activity artd-tt copy of that resolution is received by
<br />1�
<br />the Charitable Gambling Control Board within 3Vdays of the below noted date.
<br />.011 . I
<br />24,. City/Coun (Local 1--alLiverning Body)
<br />n
<br />Signature of Person Re'rceiving Application:
<br />Township: If site is located within a township, please complete items 24
<br />and 25:
<br />25. Signature of Person Receiving Application
<br />Titlie:
<br />Township Name
<br />White Copy—Board Canary—Applicant Pink—Local Governing Body
<br />
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