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Gambling License Application Page 2
<br />Type of Application: 0 Class , A Ell Cllass B 00ass C D Class D
<br />X'es ONo 231. Is gambling premises located within city limits?
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<br />X-Yes o 24. Are all garribling activities conducted at the premises listed in #,19 of this application? If not, complete a sepal!
<br />,application for each premises (except raffles) as a separate licernse is required for each premises.
<br />%Yes[INo 2,5. Does organization own the gambiling premises? If no, attach copy of the lease with terms of at least one year.
<br />C]Yesl:]No 2,6. Does the organization lease the entire premises? If no, attach a sketch of 27. Amount of Monthly Rent
<br />the premises indicating what portion is being lease�dl. A lease and sketch $
<br />is mot required for Class I D, applications., I
<br />E]Yes;KNo 28. Do you plan on conducting bingo, with this license? If yes, give days and times of bingo occasions:
<br />Days, T'imies,
<br />E.-Ne s E N o 2,9. H a s t he $ 1101 F 10,010 fi'ld e I ity bo �nd re,q u i red by M i n n lesioit,ia St atute s 3i4 9. 20, bee n obtal ne d 7 Atta c h co p y of bo n d.
<br />30. Insurance Company Name
<br />31. Bond Number
<br />321,. Lessor Naim,e 33. Address 34. City, State, Zip
<br />35. Gambling Ma:np ier Name 36. Address 37. City, State, Zip
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<br />72Q7
<br />38. Gambling Manager, Busiiniess Phone 39., Date gambling manager became
<br />( 4 / 2.0, ) 4 yxiii-ow ? member of organization:
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<br />By my signature below, local law e�nif oircement off icers or agents of the, Board are hereby authorized to enter upon the sitel
<br />at any time,, giambling Isi being conducted, to observe the ga�mbiltng and to enforce the law for any unauthorized game or
<br />practice,
<br />BANK RECORDS AUTHORIZATION
<br />Biy my signature below, the, Board is hereby authorized to inspect the bank records of the General Gambling Bank Account
<br />whenever, �niecessa ry to f ulf 111 requi r,em�ent�s of current gam bling rules and law.
<br />5
<br />147TWIF
<br />I hereby declare that:
<br />i I have read this application and all information submitted to the Board;
<br />2. AIII information submitted is true, accurate and complete;
<br />3. Alll other required information has been fully disclosed
<br />4. 1 am the chief executive officer of the orglani , zation;
<br />5. II assume full responsibility for the fair andl lawful operation of all a�ctiivities to be conducted:
<br />6. 1 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 byjhose laws. and rules, including a� endments thereto.
<br />40�. official„ Legal Nam g�a
<br />Name of Orni tilon 411. Signature (must be signed by Chief Executive Officer)
<br />10% 7.7j..J.�
<br />1 ex-
<br />Title of Signer
<br />ACMIOWLEDGEMENTOF NOTICE BY'�LOC,AL GOVERNING BODY
<br />I hierelby ackinowledge receipt of a copy of' this application. By acknowledging receipt,, I admit having been served with
<br />-joticie that this application wili be reviewed by the Charitable Giambling Control Board and if approved by the board, will
<br />beicome effective 30 days from the date of rielceli'pt (noted below), unless a resolution of the local governing body is passed
<br />which splecifically disa l�owis su6h activity and a copy of that resiolution is received by the Charitable Gambling Control
<br />Board within 30 op�Ls of the below, noted date. _
<br />4,2. Na e of City or County (Local Governing B'ody)
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<br />Signature of (per on r -wing ng applicAtion
<br />II r
<br />X
<br />Ti 'lei Date received (30 day period
<br />be g i n s from this d ate)
<br />Lit
<br />44. Name of Person de�livering application to ILocanll Governing Body
<br />C&0001 -,02 (8/861V
<br />White Copy-Board
<br />If site is located within a township, item 43 must be completed, in
<br />addition to the county signature.
<br />4,3. Name, of Townshl,.1
<br />Signature of person .receiving application
<br />Q
<br />Title
<br />Canary-Applicant
<br />Pink-Local Governing Body
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