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,G 230(0/09) <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 />Organization <br />C4 A -. VFta. <br />Address (street or post office box number) <br />e A <br />License number <br />�}- 00 y3 / /77 <br />City <br />57 f", -4v:. <br />Stele Zip code <br />Phone number <br />/11 4- .,bS /6 c 677- 03 v7 <br />Off -Site Informttionr\\\�ayK a �\ \ `\•.\i\ `�Ou� Y\ a\: •N����\ �a�•la�t��:: u` Stat\\S <br />1 Name of location where off site gambling mil be held <br />1/E N SAttJT- PAUL M1u4UESdt-A 55//3 <br />2 Address of on•site location City or township State Zip Code <br />7--S(4. R(cc STREET" FEMRUARQ r -ru 1990 <br />3 Date of on e•day event <br />FE-B, (S (990 &v& . <br />11as your organization conducted olfsito gambling oars es No ❑ If yes, what was dale of event? <br />4 <br />`UAN IE L O�DA R. 1,, g00.702 6t2 -37+ ~(3S7 <br />5 Namo of chief executive officer (please print) 'posture 1 c • �xecutive Icer Date Phone Number <br />Local Governm n t Acknowledgement r\. m waua tu E <br />a \ \ \S.QSMA(QVA \ \:\ <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 tho 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 bo 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 ) <br />City or county name <br />et O/ //AA' �ifsmog <br />Si y`I o of porson re iving application <br />Township <br />Township name <br />Signature of person receiving application <br />Date received <br />A/.st/W,l e47G r gi 7 /910 <br />Title <br />Date received <br />Attach a copy of the lease for the oft -slte 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 board use only <br />Approved 0.,..,._.....Denied' <br />