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Charitable Gambling n1rol Board <br />ay <br />Rm NI -4�75 Gr�iggs-Mid Bldg. For Board Use nlly <br />1, 1821 University Ave., Paid Amt: <br />St. Paul, IMIN 51510�4,-3 <br />183 <br />Check No <br />.. <br />(612) 642-0555 Date: <br />GAMBLING LICENSE RENEWAL APPLICATION <br />1, i I <br />LICENSE NUMBER: EFF. DATE: 4101fia", AMOUNT OF FEE: <br />1. Applicant— Legal Name of Organization 2. Street Address <br />A- T% <br />B DALE M%EONS CL,LB r.A*iX)1 kirta DjRA71e Street <br />3. City, State,, Zip <br />Roseville, AN 551113 <br />6'. Name of Chief Executive Officer <br />Paul Kamm <br />4. County <br />nape <br />I "Sey <br />9, <br />15. No. of Active Members <br />128 <br />17. Monthly Rent: <br />OATH <br />I hereby declare that <br />1. 1 have read this application anid all information submitted to the Board; <br />2. All information submitted is true, accurate and complete*, <br />3. All other required information has ibeen fully disclosed; <br />4. 1 am the chief executive officer of the organization; <br />S. I assume full responsiblility for the fair ands lawfull operation of all activities to be, conducted; <br />6. II will familiarize mysellf with the laws of the State of Minnesota respecting gambling and ruies of the board and agree, if licensed, to abide by those <br />laws and rules, incluidiingi amendments thereto., <br />23. Official Legiial Name of Organization Signature (Chief Executive Officer) Date Title IL <br />Brnale �Iens 'Clu�b Tnc. <br />24. Ci�tyigount y Name (Local.,Governing� Bod <br />r .1 ' <br />Sigaa lure of Person Receiving Application: <br />Township: If site is located within a township, please complete items 24 <br />and 21,,5: <br />215. Signature of Person Receiving Application <br />Ti Datg, Received (,thiis date begins 30 day period) Titlle.* <br />'.- r / -0 <br />JW dr <br />Name of Person Dielivering Application to Local Governing Body: <br />Township Na,m e <br />8G-00022-01 (5/87") IL) White Copy— Board Ca,nary—Applicant Pink—Local Governing Body <br />