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"49 AN <br />Jr% <br />Ciamblirtg License Application <br />Type of Application: 04C[ass A I lass B 0 Class C ElClass D <br />ElIYesXNo 23. Is gambling premises located within city limits? <br />-sONo 24. Are all gambling activities conducted at the premises listed in, #191 of this application? If not, complete a separate <br />application ' <br />1 for e a c lh pre mi se�s (except raffles) as a se pa rate I i�ce nse is required for each premises. <br />[1YesXNio 5. Doles organization <br />owns the gambling premises? If Inca, attach copy of the lease with terms of at least one vear. <br />KYOSONo 261. Does theorg any <br />zation lease the entire premises? If no, attach a, sketch of <br />the �ptemises indicating what portion is being leaded. A lease and sketch <br />is not required for Class I D applications. <br />27. Amount of Monthly Rent <br />00 P DLT'no S <br />%.0 -1 . <br />I WYes,ONIo 28,. Do you plan, on conducting bingo with this license? If yes, give days and times of bingo occasions: <br />Day's Times <br />M1 4110- ON M�q t <br />MYesElhlo 29. Has the $,10,,000 fidelity bond required by Minnesota Statutes 349.,20 been obtained? Attach copy of bond. <br />30. <br />Insurance Company Name <br />31. <br />Bond Number <br />oft <br />A <br />It 7^w T <br />AJRI�7C 11 AGa, f <br />A <br />32. <br />Lessor Name <br />33. Address <br />34. City, State.Zip <br />I <br />w, S% -Tfjj,rr ... - r I r =MTER, <br />A /Q L9 I <br />1 <br />35. Gambling IManlager Name <br />1P r-11 1 1 '-UDG" <br />2 �MT -AD <br />A* 0 UL <br />PAU 111T _-551 1 <br />36. Address <br />37. City, State, Zip <br />Tr r1r <br />Q4%. <br />- T A, IT-47 IT <br />12' MT <br />2 1 <br />11 5113 <br />ST PA IRT 5 r <br />38. <br />GiamWing Manager Business Phone <br />39. Date gambling manager beiciame <br />0" 12 '000 1414- 7 3 3 <br />member of organization: L <br />4t" <br />V 1 <br />C*TTAN_rz <br />ACKNOWLEDGEMENT OF NOTICE BY LOCALLSOVERNING BODY <br />I hereby acknowledge recelipt of a copy, of this application. By acknowledging receipt, I admit having been served with <br />notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will <br />�, e,co m e ef'fe ct [ve 30 d iay sil f' rom th e d ate of rie ce i pt (n oted be I ow)i, u n I ess a re so I utio n of th e I oc a I g ove rn 1 n g b o dy is p as sed <br />which specifically d�isail�loiws such activity and a copy of that resolution isi received by the Charitable Gambling Control <br />Bo a rd w i t h i n 3 0 • ted datei. <br />42. 11ame of City or County (Local Golv,ern�ing Body) <br />co GO 1QC <br />Signature of person -ireceiving application <br />X, <br />Date received period <br />beigins from this date) <br />CG-,01001 -02 (8/816) <br />If site is located within a township, item 43 must be completed,, in <br />addition to the county signature. <br />431. N�a�mile of Township <br />Signature of person receiving application <br />Q <br />in to Local Governing Body Title <br />White Copy-Board <br />N <br />Canary- Applicant <br />Pink-Local Governing Body <br />