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0YesXNo 2' . Does the orga�nlizatioln iieasethe entire premises? If no, attiach a sketch of 27. Amount of Mont' hl Rent
<br />the premises indicating what portion is being leased. A lease and sketch
<br />is not req�ulir,ed for Class D, applications.
<br />[D'Ye"o 28., Do you plan, on conducting bingo with this license? If y'es, give days and times of bingo occasions:
<br />3�51. Gambiling Manager Name
<br />3,81. Gambling Manager, Bul siness Phone
<br />F
<br />39. Date gambling' mainager became
<br />member of organization:
<br />37. City, State, Zip
<br />AiLk, 4.00F
<br />GAMBLING SITE AUTHORIZATION
<br />By my silg naltur,e below, local law enf or,clement officers or agents of the Board are hereby authorized to enter upon the site,,
<br />at any time, gambling' is being conducted,, to observe the gambling and to enforce the law for any unauthorized game or
<br />pract,ice.,
<br />BANK RECORDS AUTHORIZATION
<br />I the! bank records of the General Gambling Bank Account
<br />By my signature below, the Board is, hereby authorized to inspect
<br />l'ienle,ver neicessary to fulfill reqluiremenits of current gamnblingl rules and llaw.
<br />OATH::
<br />I hereby, declare that:
<br />1. I Ihnave read this application and all information submitted to the Board;
<br />2. All information submitted is true,, accurate and complete;
<br />3. Alll other required information Ihnas been fully disclosed
<br />4. 1 am, the chief executive officer of the organization;
<br />5. ll assume full responsibility for the fair and lawful ul operation of all activities to be conducted;
<br />6. I will familiarize myself' with the laws of the, State of Minnesota respecting gambling and rules of the Board and agree,
<br />if licensed, to abide by thipse, laws and rules, inclu �in - a endmie - nits thereto,
<br />40. ficial, L n 41. Sigt)ture (must be signed b ie xecutive Officer)
<br />.;gal Name of Organizae
<br />joc . e4AC 71 X Ob AF Y61
<br />_ r
<br />k1_
<br />Titie of Signer I Date
<br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I hereby acknowledge rieceipti of a copy of this application. By acknowledging receipt,, I admit having been served with
<br />notice that this application will be reiviewed by the Charitable Gambling Control Board and if approved by the board, will
<br />become, elff ectivie 301 days fr,o,m the date lo,f receipt (noted below), unless a resolution of the local governing body is passed
<br />whiich, specifically disallows such activity and a copy of that riesolution is rieceived by the Charitable Gambling Control
<br />Board with�in 30, days of thie below noted da�tel.,
<br />42. Name of'city or Co,, t 1 (Local Governing Body) If site is iocat�ed within a township, item 43 must be completed,, in
<br />��l addition to the county signature.
<br />L1A_r%A nTiz* l u
<br />43. Name of Township
<br />Signature of person receiving application
<br />Q
<br />Title,
<br />'G- 00+x'11 -02 (8/'86) White Copy-Board Cana ry-Appiicant Pink-Local Governing Body
<br />
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