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Minnesota Lawful Gambling <br />LG230 Application to Conduct Annual Off -Site Gambling <br />Page 1 of 2 <br />3/01 <br />No Fee <br />Licensed Organization Information (please print all information) � <br />Organization Name L.' e.AKE' L,z License Number (5 digits);7 3±LO 2 <br />License Expiration Date jvc, _/ 3 i _/ 2X7 Class of Organization License (A, B, C, or D) <br />Daytime Phone <br />Number (C 5 1 ) (j'3 "14 )c' <br />Name of Chief Executive Officer "Z to j'V1. s <br />(Do not list the gambling manager) <br />Gambling Premises Information <br />Name of establishment/function where gambling activity will be conducted `ice 7.71 <br />Street Address and City <br />(Do not use a post office box. If no street address, write in the road designations. Example: 3 miles east of Hwy. 63 on County Road 42) <br />Lease Requirement. Does your organization own the gambling premises? <br />El If yes, no lease is required. <br />If no, a lease agreement must be attached (you may use lease form LG224, available from the Board). However, no lease is required if the <br />only gambling activity to be conducted is a raffle. <br />tri �y wi. 5, i✓.�,� Liatcc <br />Date(s) for off-site activity up to 12 consecutive <br />days: <br />Begin date 1/ i 3/ v <br />End date to / 13 / j <br />Type of Gambling Activity. Check the box(es) for the <br />gambling activity your organization will be conducting. <br />0 Pull -Tabs CD Bingo 0 Tipboards <br />Raffles Paddlewheels <br />Local Unit of Government Acknowledgment <br />If the gambling premises is within city limits, the city must sign this application and provide a resolution. <br />On behalf of the city, I acknowledge that this application;� v --c- �, �� � <br />Print name of city <br />will be forwarded to the appropriate city officials, the city <br />\� <br />must pass a resolution specifically approving or denying v \V '-1U-' <br />this application, and a copy of the resolution will be <br />forwarded to the applying organization. (Signature c� personne(l�receivin. appli.=tion) <br />Ti#Ie��sU A 1eats 1 / (-, / di <br />If the gambling premises is located in a township, both the county a towns ' must sign this application. <br />The county must provide a resolution. <br />For the township: On behalf of the township, I <br />acknowledge that the organization is applying for an Print name of township <br />annual off-site gambling activity within the township <br />limits. <br />A township has no statutory authority to approve or (Signature of township official acknowledging application) <br />deny an application (Minn. Stat. 349.213, subd. 2). Title Date / / <br />For the county: On behalf of the county, 1 acknowledge <br />Print name of county <br />that this application will be forwarded to the appropriate <br />county officials, the county must pass a resolution <br />specifically approving or denying this application, and a (Signature of county personnel receiving application) <br />copy of the resolution will be forwarded to the applying <br />organization. Title Date / / <br />Chief Executive Officer (CEO) Acknowledgment and Oath <br />have read this application, and all information is true, accurate, and complete. I hereby authorize the Gambling Control <br />Board to modify the class of organization licen be consistent with the class of permit being applied for. <br />CEO Signature R:---...,— °`O Date 0 .' / .3 / e <br />