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Charitable Gambling Control Board
<br />R m -47'5 Giriggs-Midway Bldg.
<br />N
<br />1821 University Ave.
<br />-338
<br />St. Paul, MN 55104 3
<br />(611 2) 6420555
<br />0,
<br />IN q��111 inlin 111111
<br />For Board Use Only
<br />Paid Amt-,
<br />Check No.
<br />Date-,
<br />8. Name of'Treasurer or Person Who Accounts for Revenues 9. Business Phone
<br />— ED AL. IF T" A R 14!>T 0 em (WZ Me-Z5162.
<br />101. Name of Gambling Manager 111 . IBondl Number 12. Business Phone
<br />B cy*ry mAxis o w RPE16933 (to I Z ) (053 -0 IS (0
<br />13. Name of Establishment Where Garnbling Wili Take Place 14. County 15. No. of Active Members
<br />bwville Holiday Irm Rowvillei fl�anev 230
<br />16. Lessor Name 17. Monthly Rent:
<br />Rowville HOW* Inn
<br />y $0
<br />I& If Bingo will be conducted with this license, please specify days and times, of Bingo.
<br />Times Times Times
<br />119. Has license ever been,: 0 Revoked Date: CJ Suspended Date: El Denied Date:
<br />201. Have internal controls, been submitted previously? IR'yes, 0 No (if "No „” attach copy)
<br />21. Has current lease been filed with the board? 9 Yes 0 No ('If "No „” attach copy)
<br />22. Has current sketch been filed with the board? X Yes 0 No ('If "No," attach copy)
<br />GAMBLING SITE AUTHORIZATION
<br />By my signature be,low, local law enforcement oifficers or agents of the Board are hereby authorized to enter upon the site,, at any time, gambling is
<br />being conducted, to observe the gambling and to enforce the law for any unauthorized game or practice.
<br />BANK RECORDS AUTHORIZATION
<br />By my signature below, the Board is hereby authorized to inspect the bank records of the General' Gambling Bank Account whenever necessary to
<br />fulfill requirements, of current gambling rules and law.,
<br />OATH
<br />I hereby, declare that#
<br />1. I have tread 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. 11 am the chief executive, officer of the organization;
<br />5. 1 assume full responsibility for the fair and lawful operation of all activities to be conducted;
<br />6. II will familiarize myself with the laws of the State of Minnesota respecting gambling and rules, of the board and agree, if licensed, to abide by those
<br />laws, and rules,, including arnendments,thereto.,
<br />23. Offilcial Legai Name of Organization ,
<br />NORTH SU15019GAM �6im AssicciAno
<br />Signature (Chief Execu e Officer) Date I Title
<br />ACKNOWLEDGEMENT OF'NOTICE BY LOCAL GOVERNING BODY
<br />I Ihereby acknowledge receipt olf a copy of this application. By acknowledging receipt, II admit having been served with notice that this application will
<br />Ike reiviewed by the Charitable, Gambling Control, Board and it approved by the Board,, wiill become effective 30 days from the date of receipt (noted
<br />below,), unless a, resol�ut,ioln 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 wlithin 30 days of, the below noted date.
<br />24. City/C ty amie (LocnLLO-overning Body)
<br />Signaturie of Person Receiving Application:
<br />1L_ Z/ I la
<br />Ir
<br />lel
<br />Da,t�e Rellicei d (this date begins 30 clay period
<br />--i
<br />Township: It site is located within a township, please complete items 24
<br />and 25:
<br />25. Signature of Person Receiving Application
<br />Name of Person, Delivering Application to Local Governing Body: Township Name,
<br />CG-000212-01 (5/87) White Copy—Board Canary—Applicant Pink—Local Governing Body
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