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Charitable Gambling Control Board
<br />Rm N-,475 Griggs-Midway Bldg,.,
<br />1821 University Ave.
<br />St. Paul,, MN 515104,-3383
<br />(612), 642-0555
<br />For Board Use Only
<br />Paid Arnt:
<br />Check No.
<br />Date:
<br />GAMBLING LICENSE RENEWAL, APPLICATION
<br />LICENSE NUMBE ' R: _ B4)01113.0,01 EFF. DATE: 03/01/87 / AMOUNT OF FEE: $510
<br />1. Applicant—Legal Name of Organization 1, 2. Street Address
<br />3. City, State. Zip 1 4., County
<br />6. Narne of Chief Executive Officer
<br />81. Name of Treasurer or Person Who A,ccolunts for, Revenues
<br />5. Business Phone
<br />7. Business Phone
<br />1. Business Phone
<br />12. Business Phon,-,
<br />i &1M 11
<br />17. Monthly Rent:
<br />$0
<br />IIIJ uay I lrne a Times
<br />19., Has license ever been: 0 Revoked Date: El Suspended Date: 0 Denied Date:
<br />20�. Have internal controls been submitted previously? Fl Yes D No (it "No," attach copy)
<br />21. Has current lease been filed with the board?' I El Yes 0 No (If "No," attach copy)
<br />22. Has current skeetch been filed wilth the boiardl? 0 Yes I 13 No (if "No, PP attach copy)
<br />O,ATH
<br />I hereby declare that:
<br />1 I have read this, application and all information submitted to the Board;
<br />2. All information submitted is true, accurate and complete;
<br />3. All other required information has been fully disclosed.,
<br />4,. 1 am the chief executive officer of the organization;
<br />5. 1 assume full responsibility for the fair andl lawful operation of all activities to be conducted*.
<br />6. 1 will familiarize myself with the laws of the State of Minnesota respecting garnbling and rules of the board and agree, if licensed, to abide by those
<br />laws, and rules,, including amendments thereto.
<br />23. O�fficial Legal Name of Organization
<br />Chief Executive�ficer) Date Title
<br />r;
<br />ACKNOWLEDGEMENT OF NOTICE BY LOCALc-.61V E RJJT Mois j
<br />I �h�ereby acknowledge reiceipt o,f a copy, of thisapplication. By acknowledging receipt, 1, admit having been served with notice that this application will
<br />be rieviewed by the Charitable Gambling Control Board and if approved by the Board, will become effective 30 days from the date of receipt (noted
<br />Ibelbow), unless a resolution of the local governing body is, passed which specifically disallows such activity and a copy of that resolution is received by
<br />the Charitable Gambling Control Board within 310 days of the below noted date,.
<br />24. City/County T (Local G ing Body)
<br />ie
<br />S�igln atulre of Person Receiving,4pliciation:
<br />11 - 1 1 1111186 -
<br />Title -Date Receive this date begins, 30, day period)
<br />t1l P4 A,,A, (_ �C 11(2.
<br />Narne of Person Deliv.e.ri.ng Application to Local Governing Body-.
<br />Township: If site is located within a township, please complete items 24
<br />ainid 25,
<br />25. Signature, of Person Receiving Application
<br />'Title:
<br />Township Narne
<br />Whife Copy— Board Canary —Applicant Pink—Local Governing Body
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