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Minnesota Lawful Gambling <br />LG230 Application for One-Day <br />Off -Site Lawful Gambling <br />(8/2/91) <br />Organization <br />For Board use only <br />Base License # <br />e of Organization <br />.41/4, (iLti 4 <br />Address (street or past off office box number) <br />to <br />&tee- <br />Phone Number <br />('M)4L /77 <br />License number <br />Ex �"on <br />3/.3/7; 4 <br />State <br />1/4-4tiV <br />Zip code <br />/ 7 <br />Name of CChhiief Exewtive Officer (please print) <br />(ff nstt.e.,tra ? of abort <br />Phone Number <br />(W /A) ihq - 7W/ <br />1. Name of location where off -site gambling will be held <br />2. A r eW6T0 -site location <br />.�/J C`ity�or township State Zip Code <br />( U� E Set; /eL . X.4t2'fi St 'inn- �S // 7 <br />3. Date of ono -day event <br />4. Has your organ(Andon conducted off-site gambling this calendar year? ❑ Yes ®' No If yes, what was the date of the event? <br />vv <br />.0 atil is: <br />I affirm that the above information is true and correct <br />Signature of Chief Ex <br />tive Off <br />Local o rn r erzt Ae knowledgeme t: <br />Date <br />t/ /SAY/ <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 government (city or county) must pass a resolution specifically approving or denying this application . <br />4. A coov of the local unit of dovemmenrs resolution annrovino this aonlicafinn must be attached to this annlirafinn <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 />Cnjy„n <br />Township name <br />S <br />Signature of parson receiving application <br />Titl <br />C <br />Date redeived ,(�� <br />Lap. /0 —IL3 -9 / <br />Tide Date received <br />Is township : Organized <br />_Unorganized _Unincorporated <br />Attach a copy of the (ease for the off -site location and a copy <br />of the approving resolution from the local unit of govemment <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 D <br />Denied <br />Exeeutlwpfnetor,Oambang Control Bond <br />Page "59 <br />Date <br />