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LG230 Application to Conduct Off-Site Gambling <br />Page 2 of 2 <br />5/11 <br />Local Unit of Government Resolution of Approval <br />CITY APPROVAL for a gambling premises <br />located within city limits <br />City flame <br />Hie city council bas approved this application <br />by resolution within 90 days of the date of <br />signature below. <br />Signature of city personnel <br />Title Date <br />COUNTY APPROVAL. for a gambling pritiSe.0'i <br />located in a township <br />i <br />I County name <br />it - <br />lhe county board has approved this application <br />by resolution within 90 days oI the date of <br />signature below. <br />Signature of county personnel <br />Title Date <br />Chief Executive Officer (CFM) Acknowledgment <br />10. The person signing this application must he your organization's CEO and have their <br />name on file with the Gambling Control Board, If the Coo has changed and the current <br />GEC) has not filed a LG200B Organization Officers Affidavit with the Gambling Control <br />i3oard, he or she iT1(15i: do so at this tirne. <br />11. I have read this application, and all information Is rah% accurate, and complete, and <br />if applicable, 030 [0) Me louse 1-.0 'MS ielS StaLed 111 (WS appliCatiOn. <br />/ „..., <br />el , <br />7 - <br />:.e? ./... l_ . )ate <br />GEO m l: <br />gnaurn ../i71-Y9-(1 <br />12. Print na me Nelson Daytime phone 74:67.1c2.3 </157/ <br />Susan <br />Mail or fax to Flo attachments required. <br />Gambling Control Board <br />1711 West County Road B, Suite :300 South <br />Roseville, MN 55113 <br />v:AXz 651-639-4032 <br />Reset form I <br />ff ffrill foe made availabfe lil altiv native foribat. 1311/0 31:in1, &(affle) 03011 re1/0051. <br />Data privacy notice: Tivs inforrnation sequeslcid 011 <br />this Fu 11 (and any alSwiclanciiits) gH be used by She <br />Gd Control B001'3 (i3001(1) tt) determine your <br />organization's qualifications 10 be involveri 1 lawful <br />gambling activities in Minnesota. Yogi: organi.fialien has <br />Itbf rift 10 101050 Supply Ow: iniformagos; liowcivgr, <br />if rout oridnization relifsgs 5003ly biluf <br />the floard inely nisi he 01)10 to determine y...fin <br />000:11Z.Z111011S 0.01i0(01F, ettld, as a conse00000e, <br />milmse issue a Dein-Ids if 1.)1t16Uhuritill <br />■t0: if11001E30,i00 C0qUeSI.ed, BOard <br />vow Or gdItti.di.“”i',; <br />‘vill become pubis. 10 we Board does not ifffilie <br />permit., all information provided ET:mains privata, <br />wall the few:eel:ion of your og0nization's mune 00(1 <br />f)dctress which v11i1 i-ernain pnbfic. <br />ifilvate rfala 7010 gifianiff0tino ore avallifiiic <br />tc.: 13rfiar<li-ossifberif, ff.craiv-Isf:0if t-ibirfsc if:if:gig:es <br />Vbfic.fi y, go. <br />ci Arisniisi)tiff&fsf, f:frifacfs.fitfi ibbig0t, <br />ffibmge; <br />ciffinffibfq rrigniatir:..); es:ifffifigmf; agyffif:if <br />e :use Sr mime fifes; b.) of :ob.: Allis:Di& few:Si sal., 0. leidief <br />01;0r:0;100R f.0.001C.!00 V.P0 7i1Vcd.0. ddisl d000't ybot fiff which fa:ff.! ffi fifgai f.fiffei <br />ificbsibiefief. Lim Boani &is blissi a nevi Lise a; ..riffring 1100 030/ acmcs <br />Scs.mi srmses The ;;;;}.; cp..”.:;;; <br />