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CG 230(8/89) <br />Minnesota Lawful Gambling <br />Application for One -Day <br />Off -Site Lawful Gambling <br />Send in this application at least 60 days before your gambling activity. <br />f -13a <br />Organization License number <br />T T /E l / /} N A /J A ln ,/V h,i i/ N ,A S r/✓L- <br />Address (street or post office box number) .S-S'!i <br />�i S rr 1NAD/r (�C T, `���' 2/77 <br />Phone number <br />City State Zip code <br />p /6 /1frn/BOfJ �%/✓ <br />Off -Site Information z„ ,, ....:, <br />1 Name of location where off-site gambling wdl be held <br />VE/ve r /AN 4/4" <br />2 Address of off-site location City or township State Zip Code <br />L 1 7 ,C i C L •.S % /7 E / ,S ! ,11 �l / <br />3 Date of one -day event <br />V Z v /I/O <br />4 Has your organization conducted off-site gambling this year? Yes ❑ <br />Al n/ s'S //3 <br />No , If yes, what was date of event? <br />5 Name of chief executive officer (please print) Slgnat rep blot executivrr •tilt <br />lC y.r� a <br />41.0 yid N'' o /4._,,,6722 <br />Local Government Acknowledgeme t. <br />Date <br />Phon Number <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Board and will become effective 60 <br />days from the date of receipt by the city or county, unless the local government passes a resolution to specifically forbid the activity. A copy <br />of that resolution must be received by the Gambling Control Board within 60 days of the date filled in below. <br />City or County (to be filled in for all applicants) Township <br />City or county name <br />Township name <br />e of person ing application <br />Signature of person receiving application <br />ate received <br />Title Date received <br />Attach a copy of the lease for the off -site location <br />Mail this application and a copy of the lease to: <br />Department of Gaming - Gambling Control Division <br />Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />For <br />board use only; <br />Approved <br />erector <br />Gambh g Control <br />Oi 4 ion <br />Page 30 <br />