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03-21-05 13,16
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<br />FROM-SKYLINE BUILDERS 1-612-781-36�� T-34� P.Q2/OZ
<br />Minn�sata �awful Gambling
<br />�.G3�QR Bingo Hall �.ice��e Renewal�pp�icatior�
<br />�,M�* changesto information dir�ctly on ���� ap�iication
<br />Return I�newa� Applica[iar� By: 4/1 /2005
<br />� Bingo f-�all Information
<br />,
<br />��cense BF-E05�
<br />Capitol C�Gy �nvestments LLPdba Rosevil[e Bin
<br />2525 N Snelf�n� A��F Roseville, NIN, 55113
<br />Current License Expires: �r3������
<br />Phone (651) 697-1090
<br />Fax
<br />Renewed LicenseTerm
<br />I�- �� •� . •,.-
<br />Gaer�ner , ' ��• � Richard
<br />�aertner , Peter Marilyn
<br />Mi�ey , MarY lane
<br />r��� , Yoshi
<br />cer's Oath
<br />F-171
<br />$z.z�� ,a t.7,
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<br />, _ .�
<br />Type: l.irlli[eCi �.idk�iE�ty Company
<br />Business ID
<br />��a��� ��?20�6
<br />I Q����r� that t�is 2ppiieaGqn i� ���iecr a"cl tiY.T f' �'� [� l�' ���C Chan es in me information su�ntitteq in :h��. application wJ� ��tc'P�ti,Ail
<br />of my ��1awlECtge �;fXJ �1�2f 1 wilt faf�iltar�Z� myseli wiih'_''-14wK �y wrgi�g ICl tne gpa�� a�� (p�� u��C of government no ��Cer �^�.i 10
<br />of the 5r�F� of Minnesotadfld fU1es of the Board goverfli�lg days after me Uta�g� t1aS taken effect.
<br />gambling and agree, if licenseq, to �G�4e by thase law5 anq ruies,
<br />�nc�uA�ng 2menamenrs to rhern. � -- ~ �
<br />I declare thA[ I am qual�fied u�1C]Br [he EefIT1S Of Minnesota Rule
<br />���} 001(� :� bE h��� �5 a[7ing(? Rdl[ alttl �,��I 8biC1E l7y me �„�`_ , _
<br />restr�ct�ons set farch �n McnneSar� Rule 7862.0010 S�a�p 4. f�flflC I I�efl� Or {�i�f ex��,[i++� �'it�r
<br />I declare thd� any l�ing� 1225e agreements p4tween 4ie bt�lgi? hdll J
<br />13censee �,�•�� i�wFu1 �arnbf�ng nrg�n�z�i�ons wil spec,fcaily �qenpfy �
<br />any g0�C1s or �:�•; {� ��; t�i� organization is r�u3rzq to .�i�nLtw; �, in inj�, �7� �hie.' �xC�C�tiM� C#I'iC^_�
<br />purctia5e from rhe IeSSOC or a tT'i�rd parry vendor, U� � m1t 1!f
<br />good� and serviCE� fuii'�iSI1��7 as a p3rf ofthe le��t� agreement �'� ���C �y��� ���,r �+�
<br />tx valu�q aC t71e�r fair mdrket value.
<br />ih� ERfOr+nBGOfi �[S,rr+++� on [t11S fOfi7i ;{ry �nY arcachmenu} w�11 be used Cy me �ampt�ng c�nrrot Boam {Boara}to aet�rn't��e your q�ahf,tat�on5 to be
<br />��.3 ti�d �;. ��,atuf gambling ac� v3t�es in Mcnrtesot�, ana Ca � i� ctte Ba9rC �rt �on��ti+� a a&cr;qround inres[€qaGn�r or you. �'ov nave �� rrgnr ro retuse zo
<br />suppfy m e,n�armaGo� requesfeo, �owevar, �f ya� reC�se [a supplr �n�} Intormaoon, me R�t'J may nor De able xa �F:k••+� fi� your qual�flrat,nns and, as a
<br />oon�quence, may r2fu5@ W r' nt yov a licensa If Yau supplyme mfnrma��en reque;�ed, me Boara will ne apie mprc,c4ssy��: app�i:ac€on
<br />V-_.� name aria addrea� wlEl p� pubGc �•t5 ��z:� when re�t�ved by me °�+'� r+ll me orher �nfnrmdi�or� r��ryou prav�Ge W�u be prlvdre dara apvuG vo� �n��
<br />me �narq <SSUeS your;rr�' wnen �ne �:a� �tr: r your license, ail of ine tnformac�crs �ha� you have p�*•��� �ome G:�r3 �+_ tne process of applyfv!' Y�= ��
<br />s�cense w.[ eemme pupf�c. Ifutie Boaru does naC r95v� Ye� a I�ce���, 811 1Y12 �f1F9CITlBAO�i ,t„ nave ptawAecF rn th� � w�ss of apply�ng lor a heectise remaEn5
<br />priv3Y�, w�tt� me exCepGOn of your name ansi addresS, wn�Cn will rema�n p�puc.
<br />prrvat� 4dT� ahou[7;,, xe 7•�18?�C o�Iy [o ttle taUOwing: M ara m�mti�r5, 5[aff of tl�e prx.�� whase wnrkbs`S�gflrr�enr ��C�rq4will Viry ht:•5 atCes5 �v rhe
<br />;:•���i�a�. me k, n�rr.ra peparrment of Publ€c Satery; nc Minnesotaa�O�A�y General; Y�s Mfineso�a Comm�ssionen ot ndm�niRrat,an, Finance, ana
<br />Revenue; E�e Fti �5:�� GegESlaave AuaEtar; s]dllonal and ��terr�ar�onal gafnqtmg re9U��tory agene,es; ar,yane pursuan[ w cour� orAet; osner.•a�•�,.o � ana
<br />ageA[ies rluit ar� 557tyi�r�i� {��,�: '--.��b by s[ar� or Feqeral I:w:� �•c re accessm me �nformd[EOn, indnr�quals and agencies TCf whECi4 ia� or ieflal ortlPr
<br />aurnor�2es a?en r;� or�f���ing of �nform�udl� di[erinis nowce was g�ven; and anyonew�tn your ��'�, cnnsen�.
<br />QuE5UOn5 on [I115 fiofm slloul4 k* Qi�eC[ed ;a tne SamDti�ng Control ba rn a1651-639-4000. lr you v59 a"i?"Y, r.�iE me B�� by �s,ng me M�nnesa[a Raioy
<br />r�•••. rr and,;yk •�� p�acc a�a I ti5 55i-639��60. T1��i pu�aEic3[�on w�11 be maae avatladf� in �Itrrtla[hre farma[ 4 c+ iarge prmc, ��asli�} upon r�qu25[.
<br />P��=•{ :i+•^�� a� r.��fi��'ti ������ ha{i I�Yx,'�I� �rq snail wndurr ar requesz the �;�•��:5. t.' alcahol aro gamol��g eriforcement to � �:-.? _rr a nac+�grouna
<br />-'v�F.r�,::t7"� whlCh R'•; k�Clu�� 8 f�vi�w Ot"h!' appli�qflt'� 54urC�S Of fif58ilCii7�, ownership, an� o�ans;anonal struct„r�. AClual C9�.s i� ��;1 r.� m the i�€ti��
<br />an� renewal appl�ca��aR'�c� snail be borne Cry me a�pl�c��t
<br />upon� x� u� ma ele2r��1C2. your bpplicd�io� tor renew3l will De pfesentep �oC11e Gamnling Cex�iras Ba,3fA fpt �ns�qerarion ar a monthiy �=2��g-
<br />Ret�tn license renewal �p��Pc�tibr� ta: S�I� ot ����.�����. ��mp���g Control �a���
<br />1711 W C4 R'd B aF�06 SOuChr ROSev�lle, MN $�7,��
<br />s�r�'l^II?a C.ot�racr- Roxie f201ph =-�u rox��-�olpR@9tt�.StaTe m�l.us P_�a�? �r:;;;�a����+$ ?�k� (651)639�Q73
<br />Local GovernmentllKkClawl��lgement:
<br />(fiuSL OpCaitT ana SubrTIIC w�ti� me renewal �ppiiCdGOn, a r�*ci�,�on of appro�af from the 14ca1 wn�t of government (city or coursry}
<br />h�v�n� ���'���� over me bingo ha11-
<br />si�9a Occasions:
<br />Cample[� �� i;•�Tititne encEOSed ���i-�7�P;� Hall Octa9Far1 I�?S. fto[ac3ng Sche4ules must be prAv3de0 �n a aear le9iple format (� �'
<br />edEenclar� for e�r entlre lice�rse (]£'fr0a
<br />flttacnmen�s: � I-G3D2 �iilgo �1dI1 Occasion List, 2. L.G315R B�ngo �a i Persanne# [lYforlYldGOn, 3_ �aca: �nsz ofgovernem�nC approval
<br />i: � �r��r� (city or coun[y), ditCk 4. CheckfOf $4,00o I�cense fee payable to "State of Mi� �I�tiTn ,
<br />P�c�e i of 1
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