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a har. tabiE�a Ganbllng Control Board m N -475 rllggs- Midway, Bldg. x. ks 1821 University Aivel. St. Raoul,, MN 55104-3383 (61 )X42- oi5551 GAMBLING LICENSE RENEWAL, APPLICATION For Board Paid Check No. D- IL110ENSE, NUMBER A- 093311 -811 EFF'. DATE 114101188 1 AMOUNT OF FEE: 1. Alpplicarnt —k Legal l Name of Organization 2. Street Address I8' DAL MEN'S CLUB 2101 North Cale Street 1 rimy„ 'State, Zip County 5. Business Phone Roseville, KK 55113 (Ratlike y 612 489r 6. Name of Chief Executive Officer 7. Business Phone IPijtt1 (Mattson( ( 612 ) _ B. Name of Treasurer air Person Who Accounts for Revenues 9.13usiness Phone Robert Iiio1al 61 ) 110. Mane of Gambling IManager 111. Bond Number 12. Business Phone oinn lexter A RP 12#44 1 , (Name of Estabilishmient where Gambiling Will Take Place 14. County 15. No. of Active Members (tens E1uII R'osev111s Ramsel 128 116. Lessor Name 17. Monthly Rent: _........ .... _ ....................... to 16. It Bingo will be conducted wwithi thiis license, (please specify days and times of Bingo. Days Times N [days Times l Days Times 19. Has incense ewer been" Revoiked Date: Buaspend+ed Dale; Denied mate: 201. Have internal controls been submitted previously? :: Yes No ('lf "No." attach copy) 2"1. Has current lease been filed with thle board?' L] "Yes No (ilf "No,,, attach copy) 22. Has current sketch, been filed with the board? I 0 'Yes 0 No (if -No," attach copy) GAMBLING SITE AUTHORIZATION By my signature (below, Vocal law enfo rice rnent officers or aglents of the Board are hereby authorized to enter upon the site, at any time, gambling is being coinducted. to observe the garnlbling, and to enforce the law for any, unauthorized game or practice. BANK RECORDS AUTHORIZATION By my signature Ibelo1w. the Board is hereby authorized to inspect time bank records of the General Gambling Bank Account whenever necessary to ttiiltIl r uiremi nts� of curren t g arblirg rules and law. OATH I hereby declare that: t l have, read this iapplicalion and all information suabmiitted to the Board: 2' All unformrnation suubmni'tted is true. accurate and complete; . All other required int'ormatnon has been fullly disclosed 4 1 .gym the chef +executivee officer, of the organizatton 5 1 assume full responsibility for the fair and lawful operation of all activities to be conducted: 6 l wwnlllli familiarize, myself with the Ilaws, of" the State of M' innesota respecting gambling, and rules' of the board l and agree, if licensed, to abide by these laws and rules. including amnenldments thereto. 23. Official Legal INamie of Organization ignatuure ('Chief Executive Officer) date Title Ile?"•', I Ihereby a acckinowlledgre receipt, of a copy of this application. By a ncknowrvledlgvng receipt. I admit hanviirng been served with notice that Ibis Pp lication will be reviewed by the Charitable Gambling Control (Board and if' approved by the Boaroi. will become effective 60 days from the date of receipt (noted below), unless a resolutiiorn of the focal governing body is passed which specifically disallows, such activity and a copy of that resolution is received b (hie haritalblue Gambling Control Board within 601 days of the below noted date. y 24. aty/ ounty Nanrm D^ 0- �- - S'. If _ 1� (Local � overniing Body Township: if situ is located within a township, please complete items 24 I _r iki 4 / and 5 Signature of Pe#ni Relceiiviirlg Application: 0 Title Date Received 1( is date be,g�ins 6iO daiy period) 1612 — 0i Name of Person, Delivering Application to Local Governing Body: 25. Signature of Person Receiving Application Towwrnship Name CG-0002-2-02 (8159) White Copy —Board Canary— Applicant Pink —Local Governing Body