Laserfiche WebLink
LG230 <br />(11/15/90) <br />Organization' <br />Minnesota Lawful Gambling <br />Application for One-Day <br />Off -Site Lawful Gambling <br />tift <br />Name of Organization <br />ft-r''L Asccr, of 7 p Ser✓ <br />N <br />Phone Number <br />( &iz) e3S = 44'7.7 <br />License number <br />Expiration Date <br />Address (street or post office box number) <br />Cy State <br />l_0OA-(WGTON is) 6.5113 1 <br />e oj.Chief Executive Officer (please print) <br />iM K 44 wmw <br />Zap code <br />Phone Number <br />(b/z6) <br />O Site F <br />orntatton'; <br />1. Name of location where off -site gambling will be held <br />VENE/Z W NttJ <br />2. Address at off-site <br />von <br />age 7ttex <br />L iit1 -Ls « AN RO�t <br />City or township <br />tate <br />SS //3 <br />Lp Code <br />3. Date of one -day event <br />oar z, 1 ) co <br />4. Has your organizadon conducted off -site gambling this calendar year? <br />❑ Yes Eilei If yes, what the was the date of event? <br />/ / <br />'Oatit'< <br />I affirm that the above information is true and correct <br />J <br />Print e <br />I> tt.l4 <br />Date <br />Tay -9J <br />ocal G <br />.L overnment Aekrtouzledgemer <br />1. The city must sign if the gambling premises is located within city limits. <br />2. The notmty AND hwnsj7ja must sign if the gambling premises is located within a township. <br />3. I have received a copy of this application. <br />4. The local govemment (city or county) must pass a resolution spedfically approving or denying the application . <br />5. A copy of the resolution approving the application must be attached to the application. <br />6. Applications which am denied by the local govemment should not be submitted to the Gambling Control Board. <br />City or County (to be tilled in for all applicants ) <br />City or county name <br />Township <br />Township name <br />Signature of person receiving application <br />of person receiving application <br />Title Date received <br />Title Date received <br />Is township : _Organized Unorganized Unincorporated <br />Attach a copy of the lease for the off -site location and a copy <br />of the approving resolution from the local governing body <br />Mail this application to: <br />Department of Gaming - Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Roseville, MN 55113 <br />D:�nied!11 <br />EsnetttiveDteclor, Gambling: ;Control Dived.° <br />Oapartmem of Gaming <br />Page 36 <br />