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25. Amount of Rent Per
<br />Month or Bin nglo Occasion
<br />$ 600
<br />26. I Dlol you plan, on conducting bingo, with this license? If yes, give days and times of bingo occasions.
<br />Day Time Day Time Day Time
<br />es loo 7 IHlas the $10,10010 fidelity bolmndl required by Minnesota Statutes 349.20 been obtained?
<br />28. Insurance Company Name (not agenicy niame) 29. Bond Number
<br />United FiLre, and Casualty Col. 51-070572
<br />30. Lessor Name 31. Address 32. City, State,Zip
<br />Oil Mexi,co, 11754 North Liexif,ngton Roseville, MN 55113
<br />33. Gambling Manager Na me
<br />Robert R.1 Er' ci ill a,n3m.
<br />36. Gambling Manager Business Phoiniie
<br />1 612 11 2,28-11�58
<br />34. Address
<br />960 Goodri i ch
<br />35. City, Statet Zip
<br />St. Paul, MN 55105
<br />317. Date gambling manager blecarne
<br />member of organization: rMonth 8 Year 6
<br />DIYesONo .38. Has the license termination form been, completed? Atta,chi copy.
<br />OYes Oft 39. Has the compensation schedule been approved by the organization? Attach copy.
<br />40. List', the day and time of the regular meeting of the organization. Day Time
<br />41. Blank Nam -8 142. Bank Address 43. Bank Account Number
<br />By my signature below, local law enforcement officers or agents, of the Board are hereby authorized to enter upon the site at any
<br />time gambling is being conducted to observe the gambling and to enforice the law for any unauthorized game or practice.
<br />BANK RECORDSAUTHIORIZATION I
<br />By my signature below, the Boaird is hereby authorized to inspect the bank records of the gambling bank account whenever
<br />necessary, to fulfil] requirements of current gambling rules and law.
<br />I hereby, declare that: OiATH
<br />1. 1 Ihave read thiis application and all information submitted to the Board;
<br />2. All information submitted is true, accurate and complete-,
<br />I A111 other required information has been fuilly disclosed;
<br />4. 1 am the chief executive offlice!r of the organization.-
<br />5. 1 assume full responsibility for the fair and lawfull operation of all activities to be conducted;
<br />6. II will familiarize myself with the laws of the State of Minniesota respecting gambling and rules of the Board and agree, if
<br />ficensied, to abide by those laws and rules, including amendments thereto;
<br />7. IMiamber shiplist of the organization will be available within seven dal ysaft...e.. r it is requested by the board.
<br />44. Off i1claillill, Legal Name of Organization 1451, Signature (must b Chief Executive Officer)
<br />SAIN
<br />Title of Signer
<br />PRIN
<br />�11111111111110_ -
<br />01/17/1989
<br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I hereby acknowledge recelipt of a copy of this application. By acknowledging receipt, I admit having been served with notice that
<br />this application will ble reviewed by the Chia,r,itable Gambling Control Board and if approved by the board,, will become effective
<br />601 days, from the date of receipt (noted bellow) unless a resolution of the local governing body is passed which specifically
<br />disiallows such activity and a copy, of that resolutionils, received by the Charitable Gambling Control Board within 60 days of the
<br />below niotied, date.
<br />46• N a,me of City or County (Local Governing Body) If site is located within a township, item 47 must be completed, in
<br />� a aldd,itioni to, the county signature. If township is not organized,
<br />C31.ty of Riolsevil,Ie county must', sign.
<br />Signature of Person recelvl application 47. Name of Township
<br />Title
<br />IL
<br />Date received (610, day period Signature of person receiving application
<br />begins f r,oimi this date)
<br />071 1 X
<br />48. =on dl ve g Titile
<br />tppllicationi to Local Governing Body
<br />White Copy-Board
<br />Page 2 of 2
<br />Canary - Applicant
<br />Pink-Local Governing Body
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