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ti <br />6L ,�j <br />Charitable Gambling Coinitroil Boa�rd <br />- <br />.9.. <br />Room N�-475 Griggs7lVlldway Build" <br />i tng� <br />1821 University Aveiniu�e <br />St.i Paul�, Minnesota 55104-33831 <br />W IN <br />FOR BOARD USE ONLY <br />PAID <br />AM <br />CHECK# <br />DATE <br />�4., ApIplica�nt(Offici,a�l, legal name Cif or,ga�nl ization) <br />I-aRv *14— <br />A. 11TOITIHIM Q1111 11,7=ff <br />MQp_:_kTQFFa,,i <br />6.1 City,, Sitiate, Zip <br />-a rd <br />1 1 5. Business Address of Organization <br />-1-A-1 2001 B 01NAG-- LE � <br />8. Business Phone Number <br />612 L 61.) 1 7 - � n`c'-r, 8 0 <br />17. Name of Chief xecutivie Officer <br />Title <br />BOA.M PR"Z-iDZ'.7 m* EXIMi a <br />I Business Phone (Number <br />18. Name of treasurer or person who accounts for other revenues <br />of the organization. - <br />J0119; IMTEL TREiiii[RER <br />Title <br />TR&Augiiiii2 M=o C01-i HARKETEi <br />0011-7,1',* 1AIARKIii-47G <br />'7 Pa-(4S01,',?,1!EZj Fir -11 COI Y�l <br />1, 91. Name of establishment where gambling will be <br />conducted <br />K"_wI10"-j7-S 017 COM110-US HALL COUI-CIL 402 <br />2 1.1 City, State,, Zip <br />1" _n <br />A.0 M41 <br />0 AJ <br />,CG- i000 1.02 181861 <br />C, <br />Cp <br />White Copy-Board <br />Business Phone Number <br />( 01 2 ') 229— 1 <br />20., Street address (not P.O. Box Number) <br />2555 -.7.10,RTH v.,,rELLr_,,G AVE, S4716 P.,,=, Ki F'or'*113 <br />22. County (w' Mere gambling premises is located) <br />AI <br />S FJY <br />.......... I ........... <br />Canary -Applicant <br />Pink-Local Governing Body <br />