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Gambling License Application Type of Application: .' I Class A Iii Class B [j Class C lJ Class D Page 2 is_, No 23. Is gambling premises located within city limits? txYes c. No 24. Are all gambling activities conducted at the premises listed in # 19 of this application? If not. complete a separate application for each premises (except raffles) as a separate license is required for each premises. [xYes: I No 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. [lYes, 'No 26. Does the organization lease the entire premises? If no, attach a sketch of 27. Amount of Monthly Rent the premises indicating what portion is being leased. A lease and sketch I $ is not required for Class 0 applications. eJYes CCNo 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: Davs Times JXj Yes [J No 29. Has the $10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained ? Attach copy of bond. 30. Insurance Company Name 31. Bond Number Un' 51-54668 32. Lessor Name 33. Address 34. City, State,Zip n/a 35. Gambling Manager Name Russell W. Trout Sr. 38. Gambling Manager Business Phone ( 61~ ) 483-3535 36. Address 700 W. Co. Rd. C 39. Date gambling manager became member of organization: I 37. City, State, Zip Roseville MN 5511 Septa 1978 GAMBLING SITE AUTHORIZATION By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any time, gambling is being conducted, to observe the gambling and to enforce the law for any unauthorized game or practice. BANK RECORDS AUTHORIZATION my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account ....enever necessary to fulfill requirements of current gambling rules and law. OATH I hereby declare that: 1. I have read this application and all information submitted to the Board; 2. All information submitted is true, accurate and complete; 3. All other required information has been fully disclosed 4. I am the chief executive officer of the organization; 5. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree, if licensed, to abide b those laws and rules, includin amendments th eto. 40. Official, Legal Name of Organization 41. Sign must be si ned Rosetolffl Memorial Post No. 542 x IfIl1/} Title of Signer Date Commander ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will become effective 30 days from the date of receipt (noted below), unless a resolution of the local governing body is passed which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30 da s of the below noted date. 42. Name of City or County (Local Governing Body) If site is located within a township, item 43 must be completed, in addition to the county signature. City of Rosevi11e 43. Name of Township X Title "- . >~ 11..JAt.JC E ~\ R. Date received (30 day period begins from this date) Ill): 44. Narrye of Perso~ deliverin~a~plication to Local Governing Body CJ-f.,f!-t.f~. M-Ld (p I (!Le. CG.0001.02 (8/86) Signature of person receiving application X Title White Copy.Board Canary.Applicant Pink.Local Governing Body