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#)I <br />25. Amount of Rent Per <br />Month or Bingo� 011ccasion <br />$ <br />0.i <br />26. Do you plan on conducting bingo with this ficense? If yes, give days and time of bingo occasions. <br />Day Time Day Time Day Time <br />GAMBLING SITE AUTHORIZATION <br />I my signature be�low, local law enforicernient 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 enforce the law for any unauthorized game or practice. <br />BANK, RECORDS, AUTHORIZATION <br />By may signature below, the Board is hereby authorized to inspect, the Ibank records of the gambling bank account whenever <br />necessary to fullf illl requirements of current gambling rules and law. <br />thereby declare thiat.'s, OATI-I <br />1. 1 have read this application and all information submitted to the Board; <br />2. All l inf ormation submitted is true, accurate aundl complete; <br />31. Al1l other reqluired information has been fully disclosed; <br />4. 1 am the chief executive officer of the organization; <br />B. 1 assurne f u I I res Pon sli bii I ity for t he fair and I a wfu I operation n of all activities to be co nd u cted - <br />16. 1 will familiarize myself' with the laws of the State of Minnesota respe�cting gambling and rules of the Board and agree, if <br />licensed,, to abide by those laws anal rules, including amendments thereto; <br />7. M e m be rWp jl i s,t, of the orgian izatio n wi I I be available with i n seven d, aAs after it is requeqted by the board. <br />S, <br />44. Official, Legal Name Nae of Organization �45. 1 i tug st bes I Chief Executive ve Officer) <br />x <br />Title of Signer I Date <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL, GOVERNING BODY <br />I hereby acknowledge recleipt of a copy of this, application. By acknowledging receipt,, I admit having been served with notice that <br />this application will be reviewed, by the Charitable Gambling Control Board and if approved by the board,, will become effective <br />60 dray's f'r,olm the date of receipt (not,ed below) unless a resolution of the local governing body is passed which specifically <br />disallows such activity and a copy of that resolution is received by the Chantable Gambling Control Board within 60 days of the <br />below, noted date. <br />4,16., Name of City, or County, (Local Gover'ning Body) <br />40M <br />I <br />Siginaiture of pers n receiving applicatilon <br />X V1 <br />Title Date received (6101 day period <br />begins, from this date) <br />_4;7- I : 1 10, <br />4,8., Name of person delivering applicationtoLocal Governing Body <br />COG-00011 <br />W'h�ite Copy-Board <br />If site is located within a township, item 47 must be completed, in <br />addition to the county signature. If township is not organized,, <br />county must sign. <br />47., Name of Township <br />Signature of person receiving application <br />x <br />Title <br />Canary-Applicant <br />Page 2 of 2 <br />Pink-Local Governing Body <br />