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Gambling License Application Type of Application: VJClass A ❑Class B ❑Class C ❑Class D Page 2 lx1Yes No %Yes ❑ No 23. Is gambling premises located within city limits? 24. Are all gambling activities conducted at the premises listed in 1119 of this application? If not, complete a separate application for each premises (except raffles) as a separate license is required for each premises. ❑ Yes 'DIN° ❑YeslNo 25. Does organization own the gambling premises? If no, attach copy cf the lease with terms of at least one year.:/, 26. Does the organization lease the entire premises? If no, attach a sketch of 27. Amount of Monthly Rent the premises indicating what portion is beinc leased. A lease and sketch is not required for Class D applications. `, [LYes ❑No 28 Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: Days �') / Times � 41JYes ❑No 29. Has the $ 10,000 fidelity bond required by Minnesota Statutes 349,20 been obtained? Attach copy of bond. If site is located within a township, item 43 must be completed, in addition to the county s gnature. 30, Insurance Company Name- -, 43. Name of Township I Date received (30 day period begins from this date) 31. Bond,Number Title 32 Lessor Name / Iff' -.� / -..iiN ill 33. Address • - J... • , f.... 34. City, State,Zip; -Li-. /1/.-/,,f i J 35 Gambling Manager Name--; /. f i i r.r. �. / 36. Address /.. / �/ '' /:`. i if ✓.'". 37. ._ /r ' City, State, Zip .1 l.' ( r7/l;i,.J,) /f i.l i 38. Gambling Manager Business Phone ( . 2 ) // . i - " J-"2 39. Date member gambling manager became of organization: ,11— // /;'..,_; GAMBLING SITE AUTHORIZATION By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any time, gambling is being conducted, to observe the gambling and to enforce the law for any unauthorized game or practice. BANK RECORDS AUTHORIZATION By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessary to fulfill requirements of current gambling rules and law. OATH I hereby declare that: 1. I have read this application and all information submitted to the Board; 2. All information submitted is true, accurate and complete; 3. All other required information has been fully disclosed 4. I am the chief executive officer of the organization; 5. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 6. I will fami'iarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments thereto. 40/ Official, Legal Name of Organization 41 . Signature (must be signed by Chief Executive.Officer) 1.:.; _ _ .'7 X - Date Title of Signer ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit 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 effective 30 days from the date of rt,ceipt (noted below), unless a resolution of the local governing body is passed which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30 days of the below noted date. 42. Name of City or County (Local Governing Body) / ' ; If site is located within a township, item 43 must be completed, in addition to the county s gnature. Signature of person receiving application 43. Name of Township Title i' Date received (30 day period begins from this date) Signature of person receiving application X 44. Name of Person delivering application to Local Governing Body Title CG- 000102 (8/86) White Copy -Board Canary - Applicant PAGE -4 Pink -Local Governing Body