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Page 1 of 2 <br />Minnesota Lawful Gambling 4/00 <br />Application to Conduct Annual Off -Site Gambling - LG230 <br />For Board Use Only <br />Licensed Organization Information (please print all information) <br />Organization Name / n'' de a i " License Number (5 digits) 4t'2 /.9 <br />License Expiration Date 3 / 3/ / ,nd05-e: <br />_ <br />Clas of Organization License (A, B, C, <br />Daytime Phone <br />Number ((.6/ )- <br />or D) ,p <br />, <br />Name of Chief Executive Officer a /404 <br />?std*- j <br />-'s• <br />(Do not list the gambling manager) <br />Gambling Premises Information <br />Name of establishment/function where gambling activity will <br />Street Address and City ,9°,fb /l% <br />�f / Dot's <br />be conducted ean an <br />/ <br />9 <br />e�irPz c 4 Mn' <br />(Do not use a post office box. If no street address, write in the road <br />Lease Requirement. Does your organization own the <br />designations. Example: 3 miles east of Hwy. 63 on County Road 42) <br />gambling premises? <br />may use lease form LG224, available from the Board). <br />activity to be conducted is a raffle. <br />If yes, no lease is required. <br />d If no, a lease agreement must be attached (you <br />However, no lease is required if the only gambling <br />Date(s) for off -site activity up to 12 consecutive days: <br />Begin date 3 / _ / O.>L -- <br />Type of Gambling Activity. Check the box(es) for the <br />gambling activity your organization will be conducting. <br />,,/ <br />End date g' / '7 /62✓ <br />E�Pull -Tabs I 1 Bingo <br />1 1 Tipboards <br />1 1 Raffles 1 I Paddlewheels <br />Local Unit of Government Acknowledgment <br />If the gambling premises is within city limits, the city must sign this application and provide a resolution. <br />On behalf of the city, I acknowledge that this <br />application will be forwarded to the appropriate city <br />officials, the city must pass a resolution specifically <br />Print name of city <br />approving or denying this application, and a copy of <br />the resolution will be forwarded to the applying Signature of city personnel receiving application) <br />organization. Title Date / / <br />If the gambling premises is located in a township, both the county & township must sign this application. <br />The county must provide a resolution. <br />For the township: On behalf of the township, I <br />Print name of township <br />acknowledge that the organization is applying for <br />one -day, off-site gambling activity within the township <br />limits. <br />A township has no statutory authority to approve or <br />deny an application (Minn. Stat. § 349.213, subd. 2). <br />(Signature of township official acknowledging application) <br />Title Date / / <br />For the counter On behalf of the county, I acknowl- <br />Print name of county <br />edge that this application will be forwarded to the <br />appropriate county officials, the county must pass a <br />resolution specifically approving or denying this <br />application, and a copy of the resolution will be <br />forwarded to the applying organization. <br />(Signature of county personnel receiving application) <br />Title Date / / <br />Chief Executive Officer (CEO) Acknowledgment and Oath <br />I have read this application, and all information is true, accurate, and complete. I hereby authorize the Gambling <br />Control Board to modify the class of organization license to be consistent with the class of permit being applied for. <br />CEO Signature 9.� CCI- / %, > Date % / 16 / 1 <br />