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Minnesota Lawful Gambling 6/07 LG230 Application to Conduct Off-Site Gambling _ _ No Fee Organization name G/~7LF f%f~~V/7{'/'y ~~1/H0/~ /J/~$ License number o~,ai 9 License expiration date ~'J~ l ~/ /0~0/® Gambling Premises 7. Name of establishment or function where gambling activity will be conductedc5 Or7~~ ~'~~ /~ ~~11 ~,,~~ ~ ~/ Syr a ~ i 2. Street address and city ..~50 ~~/ KOA'1i ~ ~-/mC ~ii°l/~o4~a'f , i~/N. ..SJ/~~ ° Do not use a post office box. I ° If no street address, write in road designations. Example: 3 miles east of Hwy 63 on County Road 42. 3. Does your organization own the gambling premises? -Yes If yes, a lease is not required. i !~ No If no, a lease agreement must be attached. Use LG224 Lease for Off-Site Gambling Activity. A lease is not required for raffles. Gambling Activity I 1. Check (>I) the gambling activity your organization will be conducting. ~ t!pull-tabs -bingo _tipboards -raffle -paddlewheel I 2. Date of single day event "° 4 separate days allowed per calendar year. i 3. Dates of up to 12 consec~~uti~v~e/d~ays in connection with a county fair, state fair, church festival, or civic celebration. Begin date "`~ 3 / End date I~iLlr Z 1 event allowed per calendar year. ' I -. __ Acknowledgment • The person signing this application must be the CEO of your organization and have their name on fle with the j Gambling Control Board. • If the CEO has changed during the term of your license and the current CEO has not filed a I LG2006 Organization Officers Affidavit with the Gambling Control Board, he or she must do so at this time. I have read this application, and all information is true, accurate, and complete. q ~ Chief executive of~filc~e~r sin re L ~;y ~ %':Y - Date ~G' ll' /~~ /p'D'// ' Print name ~it'Y/Y~O1Z~~/7/~ ~ Daytime phone _~/~~- S~OS`'~O 5~~ Application and Required Attachments 1. LG230 Application to Conduct Off-Site Gambling. Mail to: Gambling Control Board There is no application fee. Suite 300 South 2. Resolution of approval from the local unit of 1711 West County Road B ' government (city or county) Roseville, MN 55113 3. Copy of the lease agreement. Or, fax to 657-639-4032 No lease is required if only a raffle will be conducted or your organization owns the premises. Questions? Contact a licensing specialist at 651-639-4000. This publication will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawrul gambling activities in Minnesota, and to assist the Board in conducting a background investigation ofyou. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board v~ill be able to processyour application. Your name and address will be public information when received by the Board. All other information you provide will be private data about you until the Board issues your permit. When the Board issues your permit, alt information you provided will become pubiicexceptforyourSocial Secudlynumber, which remains private. If the Board does not issue you a permit, all information you provided remains private, with the exception of your name and address which will remain public. Private data about you are available to following: Board members and staff whose work requires access tothe information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; Legislative Auditor; national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies specifcally authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.