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Mininesota Lawful Gambling Page <br />• <br />ii Application ._.o Annual Gambling <br />Licensed Organization Information (please print all information) <br />r <br />Or g anization Name_ �L ,e &.)66,0 d ' -0 - <br />,*Z- L, 6&�—License Number (5 digits)_.Z/9�- a o Z_ <br />License Ex p iration Date L / 6, I 3 <br />Class of Organization License (A, B, C, or D) 3 <br />Daytime Phone <br />Name of Chief Executive Officer f X 41 1.) a V 5 7 Number ( 16 S! %3 �- g <br />(Do not list the gambling manager) <br />Gambling Premises information <br />Name of establishment/function where gambling activity will be conducted L /-I K E ELM a .r1vx <br />Street Address and City Z #I , <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 />® 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 <br />only gambling activity to be conducted is a raffle. <br />Date(s) for off -site activity up to 12 consecutive <br />Type of Gambling Activity. Check the box(es) for the <br />days: <br />gambling activity your organization will be conducting. <br />Begin date ! 3 I d <br />E 'Pull-Tabs Bingo Tipboards <br />E2-Raffles ® Paddlewheels <br />End date � / 3 ! � 3 <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 � �_�) tj <br />I� CA M' (� <br />will be forwarded to the appropriate city officials, the city Print <br />name of city ` " l` , <br />must pass a resolution specifically approving or denying <br />this application, and a copy of the resolution will be <br />forwarded to the applying organization. (Signature of city personnel receiving ap ' ation) <br />Title <br />Date H /V:5 /0'Q <br />If the gambling premises is located in a township, both the county & township must sign this application. <br />The county must provide a resolution. <br />For the_townshim 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, I acknowledge <br />that this application will be forwarded to the appropriate Print name of county <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 />