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�/linnesota Lawfu! Gambling <br />�io� <br />Lt�;��U � �tCa'��t3�1 �C� [�0�1£�l.H�t Ut�'-��te CC���1lbllrl�.�_ _ �(� ��e <br />Orgarziza�ion name O��G1L . C�C.'.�.E.Lf ,�-�.�"CX°..1.�f�!'1License number �Ql / <br />License expiraiion date �� 1� 1 l�� <br />Gamks�irtg Premises <br />1. f�ame of establishsnent or functian where gamb�ing activity wili be conducted�S��u"� +`�'-r`t'C� <br />2. Street address and ciiy ��f� C� Vv . � �c� �- ��?�7 i ( ( c.� � �`�' �J �� � <br />P[Jn not use a post office box. <br />• li no street adciress, write in road designations. Example: 3 miles easi of I�wy 63 t�n County Road 42. <br />3, poes your organizatian own the garnbling pi�emises? <br />Yes If yes, a lease is not req�ired. <br />�„ iVo If no, a[ease agreement must be attached. Use LG224 Lease for Off-Site Gambling Activify. <br />A lease is not required for ra�fles. <br />Gambting,Ac#ivity <br />1. Check (�) ths gambling acti�ity yaur arganizafion wiil be eonducting. <br />✓p�i[-tabs _bingo �iipboarcis �affie _paddlewhee[ <br />2. C}ate of singla day svent r/Oi( { �, C�� . 4 separate days aliowed per calsndar year. <br />3. �3ates af up io 'f2 cans�cuti�e days in connection vJitn a county fair, state fair, church fe.�tiva�, or civic <br />celehration. Begin date End dete 1�vent allow�d per calendar year. <br />Acknowledgmen# <br />� Tf�e person signing ti�is �pplicatian musf be the C�Q af yaur organizatian and have iheir name on file with the <br />Garnbfing Gontrof Board. <br />• If the CEO has changed during the term of yaur iicer�se and the curreni C�d has not filed a <br />LG200B Qrganizafian OfFicers Affidavii wiih tl�s Gaml�ling Conirol Board, he or sY�e must da sa at this time. <br />1 have read tl�is �pplicafion, and al! infor fion �"s true, accurate, and camplete. <br />Chief executive officer signeture V i"^— Daie �/�! C�,� <br />Print nam� 1 Daytime phane ��_��� `% /,�-�, � 1� <br />Application and Rer{uired Attachrnents <br />�. LG230 Application ta Conduct Off-5ite G�mbling. M��� tn: Gambling Contraf Bnard <br />There is no application fee. 5uite 3�0 South <br />2. Resolu�ion ot approvai from the Eocai unit of 17�1 Wes# County Road B <br />government (city or county) Rosevilie, MN 55'[ 13 <br />3. Copy of th� lease agreement. Or, fax to 651-fi39-�032 <br />No lease is required if onfy a raffle will be <br />conducted or yo�rr arganizafipn owns fhe premises. Q�estions? Contaci a�icensing specialist at <br />�5 S -639-4000. <br />ThiS publicaEion wili be made availabie in <br />aiternative for�nat (i.e. largs prir�t, Brailie) upon <br />request. The information requ�s€ed on this farm <br />(snd any attachmenEs) will be used by 1he <br />Gambfing Control 6oard (Board} fo determine <br />yaurqualiticationstabeinvolved in lawfuigambldng <br />aCfiv�ties in Minnesota, and ta assist fhe f3oard <br />in conducYing a bacKground investigatian of you. <br />You have the right to refusa to suppty the <br />informatinn requesfed; however, if yau refuse <br />to suppiy this infarrr�atian, the �3oard may not be <br />able to determine your quaEificaiions and, as a <br />cnnset�uence, mey refuse ta issus you a permi€. <br />If you supply the infarmatian requested, the <br />Baardwili be abietc�processyo€arappiication. <br />Your narne and address wi§I be public <br />infarmation wlien rec�ived by ti�e Baard. Ali <br />oEher inFarmaEiot� you prpvide w(II be private <br />data about yau until the Board issuss yaur <br />permit. When the Board issues yaur permit, <br />al# infarmation you prnvided will become <br />publicexceptfaryourSocial Security number, <br />which remains private. if fhe Board dnes not <br />issue you a permit, all information you <br />provided temainsprivale,w'sft�theexceptian <br />of you€ narr�e and address w�ich wiil remain <br />public. Private data �1�out you are availabie <br />to foEEOwing: Baard rnembers and staTf <br />�nrhosework requ'sresaccesstQtheinft�rmatian�, <br />Minnesota's Departmenk of Pubiic Satety; <br />Attorney General; Commissionars af <br />Administrat�on, Fir�ance, and Revenue: <br />Legislalive AUdiior; nationai and internationai <br />gambling regulaiory agencies; anyone <br />pursuant t� court order; othar individuais and <br />agencies specifically auiharized by st�te or <br />federal law ta have ac�ess to ths iniormatian; <br />indivirtuals and agencies fdrwhich law or legal <br />otder auihorizes a r�ew use ar sY�aring of <br />inforrrtation at'ter this Notice was given; and <br />anyone wl�h your consent. <br />`ac�r �h <br />U` <br />