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Minnesota Charitable Gambling Control Board <br />GAMBLING LICENSE APPLICA710N <br />(Class A, B, or C) <br />GAMBLING SITE AUTHORIZATION <br />By my signaturie bellow, local laiw enforcement officers or, aigenit,s of the Board are hereby <br />authorized tol enter upion the site, at any time gambling is being conducted, to observe <br />the gambling and to eniforce the law f'or any unault,horized game or practice. <br />BANK RECORDS AUTHORIZATION <br />By my, signature below, the Board is hereby authorized to inspect the bank records of the <br />General Gainbling Blank Account when,ever necessary to fulfill requirements of current gamblinc <br />doles ad law. <br />I hereby declare that <br />to I hl avie rieadl this application and a-11 informat,ioln submitted to the Board; <br />2* <br />All information sulbmlitted' is true, accuraitet and complete; <br />3 all other required Information has been fully disclosed; <br />,4 1 am the chief executive officer of the or�ganizatioin; <br />591 1 assume full re�spoinsi,bility for thie fair and lawful oiperation of all activities to be <br />conducted- <br />6a, 1 wlill familiarize myself with t,he laws of the State of Minnesota respecting gambling <br />anid rules of the Board and agree, if licensed, to abide bly those laws and rules, <br />including amiendmients thereto., <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />I hiereby ackniowiliedge receipt of a co of this appili,cation. By <br />acknowledging recelptq I <br />admit having been served with notice thiat this application will <br />be reviewed by the <br />Cha,rit,ablie Gambling Control Boarld an+dl if approved <br />by the Board, <br />will become effective 30 <br />days from the date of' receipt (noted below), <br />unless a resolution <br />of the local governing <br />body is Ipassed which specifically disallows <br />sulch activity, anid a <br />copy of that resolution is <br />re'ce'ived by the, Charitable Gambling Control <br />Board within 30 days <br />of the below noted date. <br />LOC'AL GOVERNING BODY <br />Nlam e of Local ovierning Biody--- <br />ri L L L <br />q Appl i ion <br />7 1 Lal <br />nRGANIZATION <br />- <br />date Received unis is date from which the 30 day <br />fl <br />Name of Representative for Gambling License Applicant - <br />approlval begJAs), r-- <br />(serving not3iLce) <br />A <br />CC-00001-01 (12/84) White - Board' Canary - Board Pink - Applicant Goldenrod - Governing <br />(data entry) Body <br />