04-22-1992 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling Bingo Hall License Application (LG300) - Part 2 Oatfiv. I declare that this application is correct and complete to the best of my knowledge and belie /. I will familiarize myself with the Taws of the state of Minnesota and rules of the Board regarding gambling and agree, it licensed, to abide by those laws and rules, including amendments to them. Changes in the information submitted in this application will be submitted to the Board and local government unit within ten days after the change occurs. 9> igoature of chief execuUyy office e lessor Date Name (please print) Title • 10. Name of person completing this form y //9a DAVID MICHAEL SLIPY PRESIDENT PI T7ARFTH D'D(INNFI I X :ocaii Cowernment.Acknozelectgement. SEC Title Phone ( 6121 483 -2943 1. The city' must sign if the bingo hall is located within city limits. 2. The county •• AND township" must sign if the bingo hall is located within a township. 3. The local government (city or county) must pass a resolution specifically approving or denying the application. 4. A copy of the resolution approving the application must be attached to the application. 5. An application which is denied by the local governing body should not be submitted to the Gambling Control Division. • Form LG300, Bingo Hall License Application, Parts 1 and 2 • Form LG302, Bingo Hall Occasion List • Form LG315, Bingo Hall Personnel Information (for each person listed in item 4 and 5 on form LG300) • Form LG316, Bingo Hall Affidavit, (for each person listed in item 4 and 5 on form LG300) • Check for license fee of $2,500, made payable to "State of Minnesota" +er a tt Mail the appitcatton and ittuehments Department of Gaming Gambling Control Division Rosewood Plaza South, 3rd Floor 1711 W. County Road B Roseville, MN 55113 Page 76 Township By signature below, the township acknowledges that the organization is applying for a bingo hall license within township limits. City* or County ** Township ** 11. City or county name 12. Township name Signature of person receiving application Signature of person receiving application Title Date received Title - Township official Date received Name of person delivering application to local govemment Is township? organized unorganized unincorporated • Form LG300, Bingo Hall License Application, Parts 1 and 2 • Form LG302, Bingo Hall Occasion List • Form LG315, Bingo Hall Personnel Information (for each person listed in item 4 and 5 on form LG300) • Form LG316, Bingo Hall Affidavit, (for each person listed in item 4 and 5 on form LG300) • Check for license fee of $2,500, made payable to "State of Minnesota" +er a tt Mail the appitcatton and ittuehments Department of Gaming Gambling Control Division Rosewood Plaza South, 3rd Floor 1711 W. County Road B Roseville, MN 55113 Page 76