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09/07/2007 09 :03 7634247637 <br />QUALITY DRYWALL <br />Mlnnesota Lawful' Gambling <br />LG224 l aneo for OffSite Gambling Activi <br />PAGE 08 <br />8107 <br />This publication will be made available in attemative format (i.e. large pdnt, Braille) upon request. <br />The information requested on this form will become public Information when received by the Board, and will be used <br />to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. <br />5 <br />Name of legal owner of property Street address City State Zp Dayhlne phone <br />Nam e of lessor (If same as legal Street address City Sate ZIP p <br />owner, wrtte in "SAME ") <br />Name ofleased Premises Sheetaddress, or road designations City zip Daytime phone <br />Name of lessee (organization) Organtzation 'tense number Daytime phone <br />Gambling Activity <br />date offfsfe activity Ending date of off -site activity <br />1. Beginning of <br />2. Check (') the type of gambling activity that will be conducted for this off-site activity. <br />-_ pull-tabs bingo tipboards ^ paddlewheels (No lease is required for raffles) <br />— <br />Lease . Obligations <br />1. Renfta.be paid for the leased area $ _ If. none, write "0." <br />^ <br />2. All obligations and agreements between the organization and the lessor are listed below or attached to this lease. <br />Any attachmentsto this lease must be dated and signed by both the lessor and lessee. This lease (and any <br />attachments) is the total and only agreement between the lessor and the organization conducting 'await <br />gambling activities. <br />Other 'temis <br />Signature of lessor Date Signature of organization official (lessee) Date <br />Prim name of lessor Print name and title of person signing on behalf of <br />.. _, organization <br />This publication will be made available in attemative format (i.e. large pdnt, Braille) upon request. <br />The information requested on this form will become public Information when received by the Board, and will be used <br />to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. <br />5 <br />