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,_G230 <br />(8/2/91) <br />Organizaton;I <br />Marne of Organization '/ <br />Ai.0 P /9iL/� ;S a A'S / t/P/UP•P Ya imet,P1L <br />Address (stree�gqor post office box number) <br />cQ / 0 /v • (!�) I1/GS S G 6 I) c% -� I c r e e et) <br />Minnesota Lawful Gambling <br />Application for One-Day <br />Off-Site Lawful Gambling <br />For Board use only <br />Base License # <br />Phone Number <br />(4/2. ) 411'4/- £66- <br />License number <br />A -0/4717',/ - oo 3 <br />Expiration Date <br />8 /s // ys_ <br />Ci _.,c State <br />�)Cfi11e I tAtc L <br />Name of Chief Executive Officer (please print) <br />SS"// 1 <br />Zip code <br />Phone Number <br />(6%2) 996- t,5-‘ <br />Off-Stte 7r}formaton : <br />1. Name of location where offs -site gambling will be held <br />CnnVL'er- —)a -1< <br />Gress of off -site ocaoon <br />etufeIto /Ile.° <br />3. e of one -day event <br />Qk- %g <br />4. Has r ganizppan,copducted <br />l./y <br />City or township <br />Ca /, &its. <br />State <br />G hi, d.v info. S- // 7 <br />lip Code <br />amb ng this calendar year? 0 Yes (j' No If yes, whL was date okthe event? <br />4 <br />I affirm that the above information is true and correct <br />Signature <br />Locat : ernmen Acknowledgement . <br />1. The city must sign this application if the gambling premises is located within city limits. <br />2. The county AND township must sign this application if the gambling premises is located within a township. <br />3. The local unit of govemment (city or county) must pass a resolution specifically approving or denying this application . <br />4. A cony of the local emit of anvemment's resolution annmvino this anplication must be attached to this annlication <br />6. If this application is denied by the local unit of government, it should not be submitted to the Gambling Control Board. <br />City or County <br />Township <br />Ci or • • na /rq /� �9 <br />or' C �Q/iGGj.-C rt / <br />Township name <br />Signatu : of pe on race' 'ng - pplication <br />e. / <br />Signature of person receiving application <br />Ti Cp _ l / Da = received <br />77L/�(��,7 — /— <br />9477 <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 unit of government <br />Mail this application to: <br />Gambling Control Board <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Roseville, MN 55113 <br />For <br />Board Use Onty <br />Approved(0 <br />Denied El l' <br />Exscul n Ofrsctor, Qamblfng Contret Bard <br />Darr: <br />