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Gambling License Application
<br />Type of Application: lass A ❑Class B ❑Class C ❑Class D
<br />VYes ❑No 22. Is gambling premises located within city limits?
<br />Yes ❑No 23. Are all gambling activities conducted at the premises listed in #18 of this application? If not, complete a separate
<br />application for each premises (except raffles) as a separate license is required for each premises.
<br />❑YespNo 24. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year, and
<br />attach a sketch of the premises indicating what portion is being leased. A lease and sketch are not required for
<br />Class D applications. ()JO •,, ;', /._,c�,.,,.
<br />25. Amount of Rent Per 26. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions.
<br />Month or Bingo Occasion Day Time Day Time Day Time
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<br />'Yes ❑No 27. Has the S10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?
<br />28.
<br />Insurance Company Name (not agency name)
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<br />30. Le,ssor Name J
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<br />33. •Gambling Manager Narme
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<br />36. Gambling Manager Business Phone
<br />(/,9 ) / /nil- 232.5
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<br />31. Address
<br />2.2 ti 4447 / /L
<br />29. Bond,Number
<br />32. A State,Zip
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<br />34. Address
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<br />3 . City, State, Zip
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<br />37. Date gambling manager became
<br />member of organization:
<br />Month ,S"' Year KS"
<br />I Yes ❑No 38. Has the license termination form been completed? Attach copy. //71 F-1 C'/7-
<br />fYes ❑No 39. Has the compensation schedule been approved by the organization? Attach copy. /`..y r%L[
<br />40. List the day and time of the regular meeting of the organization. Day /11/41:941/ Time
<br />41. Bank Name
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<br />42. Bank Address
<br />43. Bank Account Number
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<br />GAMBLING SITE AUTHORIZATION
<br />By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site at any
<br />time gambling is being conducted to observe 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 gambling bank account whenever
<br />necessary to fulfill requirements of current gambling rules and law.
<br />I hereby declare that: OATH
<br />1. 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 conducted;
<br />6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree, if
<br />licensed, to abide by those laws and rules, including amendments thereto;
<br />7. Membership list of the organization will be available within seven days after it is requested by the board.
<br />44. Official, Legal N?me of Organization 45. Signature (must be signed by Chief Executive Officer)
<br />re.r ( i),)/l DA I-/1E /% r x
<br />Title of Signer. i / Date
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<br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />1 hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice that
<br />this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will become effective
<br />60 days from the date of receipt (noted below) unless a resolution of the local governing body is passed which specifically
<br />disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 days of the
<br />below noted date.
<br />46. Name of City or County (Local Governing Body)
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<br />If site is located within a township, item 47 must be completed, in
<br />addition to the county signature. If township is not organized,
<br />county must sign.
<br />Signature of person, receiving application,( i
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<br />47. Name of Township
<br />Title
<br />PC1 -Urj c..1.: _',t1- ..begins
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<br />Date received (60 day period
<br />from this date)
<br />Signature of person receiving application -
<br />X
<br />48. /lame of person delivering application to Local Governing Body
<br />Title
<br />CG- 0001 -03 18/88)
<br />White Copy -Board
<br />Page 4
<br />Canary - Applicant
<br />Pink -Local Governing Body
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