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Charitable Gambling Control Board <br />A ANN <br />A, I Rm, N1 -475, Grigigs-Midway Bldg. <br />0 <br />1821 University Ave., <br />St. Paul, MNl 551104-3383 <br />(6 121) 642-05115151 <br />GAMBLING LICENSE RENEWAL APPLICATION <br />For Board Use Only <br />Paid Arnt• <br />Check No. <br />Date: <br />6. Na,mle of Chief Executive Officer <br />�,Qmw <br />el A ml� g jwg %FW%al jr Ll Aim 000, A14 OCKW I <br />81. Name of Treasurer or Pers�o�nl Who Accounts for Revenues <br />ra <br />Times <br />40 1 r 440 - <br />11 if T17 &A I A ..MPW _f :& <br />:�;dd 0 Fiv _921,20 <br />19l. Has license ever been: D Revoked Date: jq, Suspended Date: ❑ Denied Date: <br />20. Have internal controls been submitted previously? Yes, ❑ No (if "No," attach copy) <br />2,1. Has current lease been filed with the board? X'Yes ❑ No (lf"No," attach copy) <br />22. Has, current sketch been filed with the board? XYes ❑ No (if "No," attach copy) <br />GAMBLING SITE, AUTHORIZATION <br />By my, signature below, local law enforcernient officers 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 />SANK RECORDS AUTHORIZATION <br />By my signature bellow, the Board is hereby authorized to inspect the blank, records of the General Gambling Bank Account whenever necessaryto <br />fulfill requirements lot current gambiling rules, and law. <br />OATH <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 />I All other required infoir,matilon has been fully disclosed*, <br />4. 1 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. 1 wifl 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 amendments thereto.. <br />23. Official Legal Name of Organization <br />ure (Chief E1xeq4,ive Officer) Date I Title <br />24. City/Wnty Name (Loealloverining �B <br />Signature of Persoh Receiving Application: <br />Title to Riecielved (%ldate begins 30 day period) <br />Township: If site is located within a township, please complete items 24 <br />anid,25: <br />25. Signature of Person Receiving Application <br />Title: <br />n Delivering 5pplic —1 Township Name <br />'Apin to Local Governing Body: <br />CG-0001221-01 (5/87) Whiite Colpy—Board Canary— Applicant Pink—Local Governing Body <br />