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Minnesota Lawful Gambling <br />Bingo Hall License Application (LG300) - Part 2 <br />Oath' <br />I declare that this application is correct and complete to the best of my knowledge and belief. I will familiarize myself with the <br />laws of the state of Minnesota and rules of the Board regarding gambling and agree, if licensed, to abide by those laws and <br />rules, including amendments to them. Changes in the information submitted in this application will be submitted to the Board <br />and local government unit within ten days after the change occurs. <br />9. Si <br />chief executive officer of the lessor Date <br />10. Name of person completing this form <br />DARCY OKONEK <br />Coca/ Co ernmen Actcriarvietlgement <br />6/21/91 <br />Name (please print) Title <br />DAVID MICHAEL SLIPY PRESIDENT <br />Title <br />SEC. <br />Phone <br />(612 )483 -2943 <br />1. The city* must sign if the bingo hall is located within city limits. <br />2. The county " AND township" must sign if the bingo hall is located within a township. <br />3. The local government (city or county) must pass a resolution specifically approving or denying the application, <br />4. A copy of the resolution approving the application must be attached to the application. <br />5. An application which is denied by the local governing body should not be submitted to the Gambling Control Division. <br />itrtgt 8`at A, pizeatOx ROMPIr OIS <br />• Form LG300, Bingo Hall License Application, Parts 1 and 2 <br />• Form LG302, Bingo Hall Occasion List <br />• Form LG315, Bingo Hall Personnel Information (for each person listed in item 4 and 5 on form LG300) <br />• Form LG316, Bingo Hall Affidavit, (for each person listed in item 4 and 5 on form LG300) <br />• Check for license fee of $2,500, made payable to "State of Minnesota" <br />rs� <br />maza .1pplZa ttion a.,rtd lktut <br />Department of Gaming <br />Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Roseville, MN 55113 <br />Page 2 <br />Township By signature below, the township <br />acknowledges that the organization is applying for <br />a bingo hall license within township limits. <br />City* or County ** <br />Township ** <br />11. City or county name <br />12. Township name <br />Signature of person receiving application <br />Signature of person receiving application <br />Title <br />Date received <br />Title - Township offiidal Date received <br />Name of person delivering application to local govemment <br />Is township? organized unorganized unincorporated <br />itrtgt 8`at A, pizeatOx ROMPIr OIS <br />• Form LG300, Bingo Hall License Application, Parts 1 and 2 <br />• Form LG302, Bingo Hall Occasion List <br />• Form LG315, Bingo Hall Personnel Information (for each person listed in item 4 and 5 on form LG300) <br />• Form LG316, Bingo Hall Affidavit, (for each person listed in item 4 and 5 on form LG300) <br />• Check for license fee of $2,500, made payable to "State of Minnesota" <br />rs� <br />maza .1pplZa ttion a.,rtd lktut <br />Department of Gaming <br />Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Roseville, MN 55113 <br />Page 2 <br />