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LG200A Rev, (9 /4/90) Minnesota Lawful Gambling Organization License Application - Part 2 Laovful' Purpose Eapendifures !' Please list the lawful purpose expenditures for which your organization will expend gambling funds. (Refer to Minn. Statute 349.12 Subd.12.) Give specific examples. !'... -. ,.. y- .. ..A ,...1 -., r • Ganbltng'Manager Name of organization's gambling manager Address City Ireneaus 1,F1. lviassman 365 Koehler RD. Vadnais Iits. ?IN. State Zip Code 55127 Organt ;atioaal lncotne anti Activities (Rtfach addiitionat sheets if necessary) Zist other activities througn which your organization raises funds. Pancake breakfast in strin7 and fail candy sales P1 yv —der: What percentage of your organization's funds are raised or will be raised through lawful gambling? 90% What other activities does your organization engage in (not fundraising)v Hearing, S i ht , . Ynttt h clzizensnip c lecal community grt„n9 +ion I declare that: •1 have read this application and all information submitted to the board; 'All information is true, accurate and complete; •AII other required information has been fully disclosed; •1 am the chief executive officer of the organization; •1 assume full responsibility for the fair and lawful operation of all activities to be conducted; •1 will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the board and agree, if licensed, • to abide by those laws and rules, including amendments to them; •A membership list of the organization will be available within seven days after it is requested by the board; •Any changes in application information will be submitted to the board and local government within 10 days of the change; and •A termination plan will be submitted to the board within 15 days of termination of all premise permit(s). •1 certify that the gambling manager is bonded and licensed as required per Minnesota Statute. 'Failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. Signature of Chief Executive Officer Date Refer to the structfons for the required attachments. REMINDER: The organization's chief executive officer and treasurer must complete the Organization Officer Affidavit, form LG 2006. Mail to: Department of Gaming - Gambling Control Division Rosewood Plaza South, 3rd Floor 1711 W. County Road 0 Roseville, MN 55113 Page 29