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Gambling License Appliciption <br />Tylpie of Applicalion: NGIass A 1:1 Chess B 0 Class C DClass D <br />s o 23. Its igambilinigipire,misesloilca�tied within city limits? <br />s.71%lo 24,. Are all gambling. activities conducted at the premises listed in #19 of this application? If not, complete a separ�_, <br />a�pplicatioln, four each premisies (except raffles) as a separate I iciense is required for each premises. <br />■ �25�.D�oies organizati-on own the g�aimbling premises? If no, attach copy of the lease with terms of at least one year. <br />)_(Yes0No 26. Dioes 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 leased. A liea,se and sketch 00 <br />is not required f or C (Mass D applications. <br />■ <br />2118. Doi y1ou plan on Icornlducting bingo with this license? If yes, give days and times of bingo occasions: <br />Days Tilimies, <br />JUIED, Soi, r T co I a cb, r. oz tj <br />1W S 3 a <br />4F <br />Hias the $1�01,000 fidelity boinid required by Minnesota Statutes 349.20 been obtained? Attach copy of bond. <br />30. Insurance Company Name <br />I L, A jO PIL A T CS pa, T &t jL <br />321. Lessior Narne <br />Al -41e& 0441.r. ooY'.1rjov- <br />A Z40 <br />35., Gambling Manaiger Name <br />L-11 <br />J-6 'i L) <br />38. Giaimibling Manager Business Phone <br />( ev I 'a ) 419 C1 . CW t <br />401 Z -2 Z I - S- Olt) <br />Ar-c!g C4=0 <br />33. Address <br />AWA <br />36. Address <br />aloe. 3e A44kiA.'C ;Pa A-P <br />31. Bond Number <br />34. City, State,ZIP <br />1 37. City, State, Zip <br />Rf;D r e- 1p't I/et. ±e aj <br />39. Date gambling manager blecame <br />member of organization: I Ndo.. <br />GAMBLING SITE AUTHORIZATION <br />rill//S <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERdING BODY <br />I �he,r,eby acknowledge receipt of a cloply of this application. By acknowledging receipt, I admit having been served with <br />noti�cel, that this application will be revillewed by, the Charitable Gambling Cointrol Board and if approved by the board, will <br />i <br />become effe,ctive 30 days f rolm the dat�el, of receipt (noted bellow), unliess a resolution of the local governing body is passed <br />which specifically disallows such activity and a copy of that resolution iis received by the Charitable Gambling Control <br />Board within 30 days of the below nioted date. <br />4,2. Name of City or County, (Local Governing Boldiy), If site is located wlithin a township, item 43 must be completed, in <br />addition to the county signature. <br />I - AP Z I LI�MIWICM <br />Signature of person rtgr4ing application <br />2= <br />x K_ <br />Title Date received (30 day period <br />begins f r,om this date) <br />A14%C"41.1 Q_ 2 <br />3/8 <br />4. Name of Person, delivering iapipli,caitioni to, Locial Governing Body <br />White Coply-Board <br />-43. Name of TownshiA <br />Signature of person receiving applicatior <br />U <br />Clanary-Applicant <br />Pink-Local Governing Body <br />