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Charitable Gambling Control Board Rm N-47'5 Griggs-Mildway Bldg. 1821 University Avie. St. PauIlI, MN 551 04-3383 ('611 ) 64210555 GAMBLING LICENSE RENEW AL APPLICATION For Board Use Only Paid Amt: Check No. Date- -T-h-ur s . Eve .1 7 1: 11 101- 11,80 10 P (613 48,3-2387 15, No. of Active members 17. Monthly Rent: "75 19. Has Ilicie nse ever been:, r; 0 0 Revoked Date: 0 Suspended Date: El Denied Date: 20. Have internal controls been submitted previously? L% Yes 0 No (if "No," attach copy) 21. Has current lease been filed, with the board? 2i Yes El No (If "o," attach copy) 22. Has current sketch been filed with the board? IN Yes El No if "No," attach copy) Times By my signature below,, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any time, gambling is being cond�ucted, to observe the ga,m�blliing and to enforce the law for any unauthorized game or practice. BANK RECORDS AUTHORIZATION By my signature below, the Board is hereby authorized to inspect the bank records, of the General Gambling Bank Account whenever necessary to fulfill reqluirements of current gambling rules and law. OATH I hereby declare that: 11. 1 have read this application and all inflormation submitted to the Board; 2. All informiation submitted is true, accurate and complete; 3, All, other required information has been fully disclosed; 4. II arn the chief exeicutive officer of the, organization; 5. 1 assume ful�l responsibility for the fair and lawfu�l operation of all activilies to, be conducted; 6. 1 �wil,l familiarize myselfwith the laws of the State of Minnesota respecting gambling and rules of the board and agree, if licensed, to abide by those laws, and rules, inicludi,ng amendments thereto. 2 1 31. Official L,ega,l Name of Organization W =_ E NAM Sivature (Chief. Executive Officer) � � .� , rte► Y`°' 7' � . r d�.+ Date Title N4 V-9 k ACKNOWLEDGEMENT OF NOTICE, BY LOCXINI GOVERNING BODY I Iherelby acknowledge receipt of 'a copy of this application. By acknowledging receipt, I admit having been served with notice that this application will be reviewed by, the Charitable Gambling Con�tr,oll Board and if approved by the Board, will become effective 30 days from the date of receipt (noted below), unless a resolution of the local governing body is passed which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30, days of the below noted date. �24. City/ County Name (Local Gioverning (Body) ,Sign�at,ure of Person Recet J g Applicati n: • LCJM f Title Date Receiid (this date, begins, 30 day period) .t,1421 110.1 Township: If site is located within a township, please complete items 24 anid 25: 2115., Signature of Person Receiving Application Name of Person, Defivering Application to Local Governing Body: Township Name 7Yr tr_ A U111 White Copy—Board Canary —Applicant Pink—Local Governing Body