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7Yes7No 216., Does, the organ ization lease the entire premises? If no, attach a sketch of 27. Amount of Monthly Rent <br />- <br />the, piremisies indicatng -what portion is being leasedi.,A lease and sketch $ <br />is not requiried for Class, D appliications. I <br />E]YesWNiol 28. Do you plan on conducting bingo, with this ficense?l If yes., g�ive, days and times • bingo occasions: <br />Days Times <br />I <br />k] Yes, I El No 29., Has the $ 1, 101,,000 f idelity bond required by Minnesota, Statutes 349.20 been obtained? Attach copy of bond. <br />30. Insuranice Company Name 31. Bond Number <br />Stiatie Surety Co., Aimherst.-A Inc 1321, Rice St. P- 312444 <br />A, e n cy, <br />32,. Lessor Name 133. Address 34. City, State, Zip <br />3151. Gambling Manag�er Name <br />Daniel J. F1 ahemy <br />3181. Gambling IManager Business Phone <br />( 612 ) 464-6299 <br />36. Address <br />22114 Jason Axel. N. <br />39. Date gambling managder became <br />member of organization <br />GAMBLING SITE AUTHORIZATION <br />37. City, State, Zip <br />Forest LakeMN 55025 <br />I <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />,I hereby acknowledge receipt of' a copy of' thils, application,. By acknowledging receipt, I admit having been served with <br />notice that this application willi be reviewed by the Charitable Gmbling Control Board and if approved by the board,, will <br />beco, m e ef'f'ie cti ve 30 d ays f ro m� the, d ate of re c el i Pt (n oted be low),, u n I ess a res o I uti o n of th e I o c a I g ove rn i n g body i s pa s se d <br />w,h,ich specifically disailows such activity and a copy of that resolution is received by the Charitable Gambling Control <br />Board within �3,0 days of the bel�ow noted date. <br />4,2,., Name of City, or County (Local Glovierninig Bioidl yl) IIf site is located within a township, item 43 must be completed, in <br />addlitioin to the county signature. <br />Wlhiite Copy-Board <br />43. Name of Township <br />Signature of person receiving application <br />Q4 <br />Title <br />Canary-Applicant <br />Pink-Local Governing Body <br />