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Minnesota Charitable Gambling Control Board <br />904 Summit State Bank Building <br />310 4th Avenue South <br />Minneapolis, MN 55415 <br />1612) 341 -7676 <br />INSTRUCTIONS: 1. Submit to above address. <br />2. PRINT or TYPE. ' <br />i . <br />Official, Legal Name of Organization <br />er 'r tiny. Y /70 <br />I. :10 <br />License Number Number of Additional Occasions <br />Requested per week r :. <br />Days of Week for Additional Occasions <br />!TO 1,l.. <br />Reasons for request: <br />- <br />)/ . ,.%c, -, /?f /S, 5,3ce,: r y 15 fl It/640 <br />/Tn? co `F do /i % / %u rjIE C' <br />'; /7;:"- 5 TO c. j }•1,{ND /75 C' /ld /e/ <br />11 /un 7#7— <; <br />REQUEST FOR MORE THAN <br />TWO BINGO OCCASIONS PER WEEK <br />Address of site (where bingo occasions will be held) <br />Z91/ i2 t e Sri?r'f7"' <br />City, State Zip <br />77--2C (A. <br />County <br />Is site located within city /town limits? <br />Wes" ❑ No <br />7" c <br />CAA-) /i,4 ri nA.1 rl4 V <br />/T' y &c �.. / i "i"G£. C,,?r✓i4T0 <br />c07 /ir,&2r /e 7-4., /3c'7 d <br />State how additional occasions are consistent with: a. Preventing Commercialization of gambling <br />b. Insuring integrity of operations <br />c. Providing for the use of the net profits only for law <br />d. Attach additional sheet if necessary. <br />1/ Cfl..J'S5 <br />-779c ;aC/c7 y <br />(77 ,/. <br />JO /C /ET 7y fo,,e 4.. f'/ <br />ul purposes. <br />TV en C !i4 2 2)1 /SG C r- U f),i <br />/ 7.5 li C+1 /v/ <br />t7 / 74 / //7-4dz i�nt r ✓w <br />/ /(. 'A ='H / l r [ j e t 1(4<, / Al'reA°/t!elz, ; A D /;1 (' e:U U,J i'�.!/t.i` (..,,tlr: /'a <br />�aiJ> if <br />4.) S r >{i (.) 5 <br />A' G y,' /a- >--e" ,f'�! 47 L /;c fi 2 / <br />rcv1: f cGUtS7 <br />Signature, Chief Executive Officer <br />'. ..1 . <br />. <br />l' l <br />: � r, ,rah re' <br />Date of Request <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />II hereby acknowledge receipt of a copy of this application for request for more than two Bingo occasions per week. By acknowledging receipt, 1 admit <br />having been served with notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the Board, will become <br />effective 60 days from the date of receipt (noted below), unless a resolution of the local governing body is passed which specifically disallows such <br />activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 days of the below noted date. <br />LOCAL GOVERNING BODY <br />Name of Local Governing Body <br />airy eR 4 /1//Ze (9Nydk <br />\ {Signature of Person Receiving Application <br />Da eceived (This is dat from which the 60 day <br />approval begins) <br />4/7 / <br />ORGANIZATION <br />Name of Representative for Gambling License Applicant <br />(serving notice) <br />CG-00003 -o1 (12/84) White — Board <br />Pink — Applicant Goldenrod — Governing Body <br />