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1-41D <br />q <br />MINNESOTA DEPARTMENT OF REVENUE <br />GAMING DIVISION <br />Mail Station 3315 <br />St., Paul IVIN 55146-33151 <br />612/297-5300 <br />4i. Applicant (Official, legal name of' organization) I 5i. �Businiess Address of Organization <br />Pi 0 ai C$1 <br />14. Number of actiive members 15. Number, of years in existence <br />Z.sc> ILA <br />Note: Attach evidence of <br />three years existence. <br />116. Name of Chief Executive Officer (Ciannat be 117. lame of treasurer or person who accounts for other <br />Garnbling Manalgier) revenues of the organization (Cannot be Gambling Manager) <br />Tiitle <br />C.--c.- *.-j -7n, 'file. 1 <br />Rusiness Phone Number <br />rL, e-_- S <br />Business Phone Number <br />1 Rd <br />18. Name of establishment where gambling will be conducted 119. Street address (not P.O. Box Number) <br />D 10 <br />201. City, State, Zip <br />:, a I <br />t ry-*. r*., <br />White Colpy-Board <br />21 . County (where gambling premises is located) <br />Page 1 of 2 <br />Canary-Applicant <br />Pink-Local Governing Body <br />