Laserfiche WebLink
Minnesota Lawful Gambling <br />LG230 Application for One -Day <br />Off -Site Lawful Gambling <br />(8/2/91) <br />organ zatton <br />Name of Organization \' %( <br />U��h� h r�in 7o.vT ASS4C,d1-) o - <br />Address (street or post office box number) <br />I1 s t l.a , C,,.. T„ I t a , tG ri . i•t i o-1 <br />City <br />Rote J�((t , <br />Name of Chief Executive Officer (please print) <br />GUb on I to 7% <br />Of f` -atte Information; <br />Phone Number <br />(641 )63S' -9600 <br />License number <br />For Board use only <br />Base License # <br />Expiration Date <br />3 -3t -`16 <br />IG�Sa V,I(< <br />State <br />Vy1 tJ <br />V)" i 5Slf3 <br />hp code <br />$5113 <br />Phone Number <br />(6 ;L) 589 -9'i63 <br />1. Name of location where off -site gambling will be held <br />2. Alidress of off-site location <br />E I 1 <br />3. Date of one -day event <br />4 (tl - ;`I <br />r <br />City or township <br />State <br />; i/—I <br />Zip Code <br />4. Has your organization conducted off-site gambling this calendar year? <br />❑ Yes agt No If yes, what was the date of the event? <br />r i <br />Oath <br />I affirm that the above information is true and correct. <br />of Chief Executive 07ticer <br />Date <br />-1 -11 -y4 <br />iocat Government Acknoivtedgeiment <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 coov of the local unit of novemmenrs resolution annrnvinn this aooliavtinn mnst he ached 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 />City or pun amen <br />Township name <br />Sign to of person re vin application <br />Signature of person receiving application <br />Title // Date received <br />fin( ,-,-(J • &.adJ --2- 7. <br />-95/ <br />Title Date received <br />Is township : <br />_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 Board Use Only;; <br />Approved ❑ Denied <br />Exe cutivatNnetor,r3ambfingiControt grili! IPS& <br />