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*M" a <br />Gambling license Application Page 2 <br />Type of Applicatlow Mlass, A 0 C,llass B EI.Class C IEl Class D <br />E]Ye%MNo 287 , Dc cu pllan on conducting bingo w,ith this license? If yes, give days and times of bingo occasions: <br />GAMBLING SITE AUTHOR1ZATION <br />By my signature below, local Ilaw enforcement officers or agents of the Board are hereby authorized to enter upon the site, <br />at an�y, time, gambilling is being conducted), to observe the gambling and to enforce the law for any unauthorized game or <br />practice. <br />BANK RECORDS AUTHORIZATION <br />Ry imiy signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account <br />,?henever necessary to f ulf ill requirements of current gambling ruilles, and (law. <br />OATH <br />I hereby declare that,-, <br />1 . I have read this application and alll information submitted to the Board; <br />2. <br />Alll information subm� itteid is true, accurate and complete; <br />3. <br />Alll other required information has been fully disclosed <br />4. 1 am the chief executive off icer of the organization; <br />5. 1 assume if ulll responsibility for the fair and llawfuil operation of all activities to be conducted-, <br />16. 1 will familiarize mysiielf wilt,h the laws, of the State of Minnesota respecting gambling and rules of the Bbard and agree, <br />if I icensied . to abide Iby those I a w s and rules, *1 n cl ud i n g 2 rin ein d ments thereto. _1000� -Wow"%L <br />40. <br />official, Legal Name of Organization 1I. S i niature(rinustbe e a�46_60_iced <br />-0 MOM <br />"17itle of Signer Date <br />Execut ive Director --- J'uily 29s 1987 <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />I hereby acknowledge rielcei'pt of a copy of this application. By acknowledging receipt, I admit having been served with <br />notice that" this applicatilon will be reviewed by the Charitable Gambling Control Board and if approved by the board, will <br />beicome eff ec,t ivie 3110 d ays f rom th e d ate of reice i pt J n oted b e low), u n I essil a reso I ut i on of the loca I gove rni n g b ody i s pa ssed <br />which specifically disalliows, such activity and a copy of that resolution is received by the Charitable Gambling Control <br />Board within 30 dlilays of the bellow noted date. <br />421. Name of City or County, (Locai Governing Body) If site, is located within a township, item 43 must be completed, in <br />City of Roseville 1� addition to the county signature. <br />Signature ofpeirsign re eiv I ing . ti A in <br />X <br />mi <br />Title (Date received (301 days period <br />% (beg in,sifriolitt <br />oil, <br />44. Name of Person, delivering application to Local Goverining­l_Body <br />Joan Kosmalski <br />White oply-Board <br />43. Name of Township <br />Signature of person receiving application <br />Q <br />Title <br />Canary-Applicant <br />Pink-Local Governing Body <br />