01-24-1990 Council Agenda - Laserfiche WebLink

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,1/4 Exb, Department of Revenue - Gaming Division jails, Mail Station 3315 T;—, St. Paul, MN 55146 -3315 (612) 297 -5300 GAMBLING LICENSE RENEWAL APPLICATION For Board Use Only Paid Amt: Date: LICENSE NUMBER: / EFF. DATE: / AMOUNT OF FEE: 1. Applicant —Legal Name of Organization 2. Street Address 3. City, State, Zip , : , , -. 4. County -,, 5. Business Phone (.; „) .... 6. Name of Chief Executive Officer . ... .; .... 7. Business Phone ( ' ') '. - ..... 8, Name of Treasurer or Person Who Accounts for Revenues 9. Business Phone 10. Name of Gambling Manager 11. Bond Number 12. Business Phone ( :1 ) ;.- . .. 13. Name of Establishment Where Gambling Will Take Place 14. County 15. No. of Active Members 16. Lessor Name 17. Monthly Rent: 18. If Bingo will be conducted with this license, please specify days and times of Bingo. Days Times Days Times Days Times 19. Has license ever been: 0 Revoked Date: ❑ Suspended Date: 20. Have internal controls been submitted previously? 21. Has current lease been filed with the board? 22. Has current sketch been filed with the board? ❑ Denied Date: 0 Yes 0 No (If "No,' attach copy) fJ' Yes ❑ No Of "No,” attach copy) 0 Yes ❑ No (If "No," attach copy) 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 familiarize 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. 23. Official Legal Name of Organization Signature (Chief Executive Officer) Date Title 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 60 days from the date of receipt (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 60 days of the below noted date. 24. City /County Name (Local Governing Body) Township: If site is located within a township, please complete items 24 and 25: Signature of Person Receiving Application: 25. Signature of Person Receiving Application Title Date Received (this date begins 60 day period) Title: Name of Person Delivering Application to Local Governing Body: Township Name • CG- 00022 -01 (4/89) White Cnne_Rn=ra Page 61 Canary — Applicant Pink —Local Governing Body