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Charitable Gambling Conitrol Board <br />R�m N-475 Griggs-Midway Bldg. <br />118'21 University Ave. <br />st Paul. MN 55104­3383 <br />(6 12) 642-0555 <br />For Board Use Only <br />Paid <br />Check No. <br />LICENSE, NUMBER: <br />11 a - d EFF. DATE.: l I AMOUNT OF FEE: <br />....... ....... <br />1. Applicant—Legal Name of Organization 2. Street Address <br />StIR110RILY00141 Alt r <br />Ent RGv-IVjjtL 22 Sox !115", <br />I City, State,, Zip 4. County R <br />II hereby declare that: <br />I. I have read this application and all information, submitted to the E3oa,rd: <br />211. All information submitted is true, acic4(atie and complete: <br />i <br />3. All other required information has been fully disclosed; <br />4. 1 am the chief executive officer of the organization; <br />5. 1 assume full reispionsibiliity 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 Mlinnesota respecting garnbling and rules of the board and agree, if licensed, to abide by those <br />laws and rules, including, amendments therieto. <br />Z3. Official Legal Name of Organization <br />Signature (Chief Executive <br />el Officer) Date Title <br />. .................... ( <br />...................... _L2 :� <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />il hereby acknowledge receipt, of a copy of this �appl�ic,a,ti�on. By acknowledging receipt, I admit having been served with notice that this application will <br />be reviewed by the Charitable Gambling Control Board and if approved by the, Board, will become effective.3"ays from the date of receipt (noted <br />below), unless a resolution of the local goveirninl g body is passed which specifically disallows s�uch activity ar(d4kopy of that resolution i$ received by <br />the Charitable Gambling Control Board within <br />..A�ays of the below noted date, <br />214. County Name, (Local Governing Body) <br />Signature of' Person Receiving Application: <br />Ile <br />He ff <br />date R�eceived (this doite (begins, 30.4av period) <br />Wr <br />F <br />ame of, Person Delivering Application to Local Governing Body: <br />i ownshlip: If site is located within a township, please complete items 24 <br />and 25: <br />A- %or - 0"o 11 w, 1 ca, 1, tA 11 w v1 F-upwin rieceiving Application <br />Title: <br />Township Name <br />CG4M22_o1 ww) <br />White Copy­Board Canary— Applicant Pink—Local Governing EWy <br />