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- 2 - <br />Minnesota Charitable Gambling Control Board GAMBLING LICENSE APPLICATION <br />(Class A, B, or C) <br />GAMBLING SITE AUTHORIZATION <br />By my signature below, local law enforcement officers or agents of the Board are hereby <br />authorized to enter upon the site, at any time gambling is being conducted, to observe <br />the gambling and to enforce the law for any unauthorized game or practice. <br />BANK RECORDS AUTHORIZATION <br />By my signature below, the Board is hereby authorized to inspect the bank records of the <br />General Gambling Bank Account whenever necessary to fulfill requirements of current gambling <br />rules and law. <br />OATH <br />I hereby declare that <br />l.• I have read this application and all information submitted to the Board; <br />2. All information submitted is true, accurate, and complete; <br />3. all other required information has been fully disclosed; <br />4. I am the chief executive officer of the organization; <br />5. I assume full responsibility for the fair and lawful operation of all activities to be <br />conducted; <br />6. I will familiarize myself with the laws of the State of Minnesota respecting gambling <br />and rules of the Board and agree, if licensed, to abide by those laws and rules, <br />including amendments thereto. <br />Off�i ga ame of Organizat <br />Her ra7m_s'e �J IS — iao S 6% <br />Signature <br />Tile <br />4: 4.4,—/,,,,,04/1.4r <br />Chi -f Executive Officer) <br />Date /('od 2/ /5SS <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I <br />admit having keen served with notice that this application will be reviewed by the <br />Charitable Gambling Control Board and if approved by the Board, will become effective 30 <br />days from the date of receipt (noted below), unless a resolution of the local governing <br />body is passed which specifically disallows such activity and a copy of that resolution is <br />received by the Charitable Gambling Control Board within 30 days of the below noted date. <br />LOCAL GOVERNING BODY <br />Name of Local Governing Body <br />I.,T'ITI.E CANADA, CITY OF <br />Signature,o Person Race' g Apppi /lc• ion/� %% (�+ L <br />�J'' <br />Date Bee ived (Ibis is date from which the 30 day <br />approve egins) <br />Dec. 20, 1985 <br />9 <br />ORGANIZATION <br />Name of Representative for Gambling License Applicant <br />(serving notice) <br />CC- 00001 -01 (12/84) White - Board <br />Canary - Board <br />(data entry) <br />Pink - Applicant Goldenrod - Governing <br />Body <br />