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Minnesota Lawful Gambling <br /> LG230 <br /> (8/2/91) Application for One-Day I For Board use.only <br /> Off-Site Lawful Gambling Base License# <br /> atto :«>;»>:;<:<:: <:: ;: < > ><< >i <n:nai:>>>>: ::::> ;;> ;>>:>::>: : `> ::;"ii:i:;lgp: `>>:>> <i<isi:<'_ >>>»;< i><i i »<R>'>;<>>M <br /> Name ofOrg ijation Phone Number License number E irationpate <br /> `rt l Li' cii e �W� ( z) 591 6 t? o? 0O36 � <br /> Add,o, <br /> (street or pest office box number) <br /> &O 3&'i • <br /> City State Zip code <br /> i'rtd/Eitt /0r4j SSi3Z- <br /> Name of Chief Executia Officer(please print) Phone Number <br /> Doha/d// /12. c ker (44z) 7?O - 4/1417 <br /> 1. Name of location where off-site gambling will be held <br /> 4-e /- Ra e gc7/1r o o :-y► <br /> 2. Address of off-site location City or township State Zip Code <br /> --39 Eel f ioacL L) FlouncL v, eL4 44 A) .5777r: - <br /> 3. Date of one-day event <br /> e, 6e, r / 99.3 <br /> 4. Has your organization conducted off-site gambling this calendar year? ❑ Yes ®No If yes,what was the date of the event? <br /> • <br /> / / <br /> OathOrtakiliMMENiiiiNINEREVEMEREENNERMEEMENVEISMORRINIESEMENEEMEEN <br /> I affirm that the above information is true and correct. <br /> Signature of Chief Executive Officer Date <br /> Y//f/F..3 <br /> 1ocatriovemmercP400wt0:4 .............:...........:.:..:..:::::::MMNEM:::n::::.:...:::.:::.:.:........................... ..:............. ..:.::.:...::..::. <br /> 1. The city must sign this application if the gambling premises is located within city limits. <br /> 2. The county AND gwnshio 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. p coov of the local unit of aovemmenrs resolution aoorovina this aoolication must be attached to this aoolication. <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 Township <br /> City or iunty name Township name <br /> /Ai (vIla <br /> Sig ture of pers•ni, 0,lication Signature of person receiving application <br /> Ti Date received Title Date received <br /> Lr iL + f— <br /> >du,duirty, 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 /> oattkVS.<Only: i>>i<.•:..`>``<i>i i'ii >< >....> ;i i<iii<:i '<> <.,....> i`i....'<.....iiia>'`` ' >;i>i<`>`mig>i<i <'i i<'i>`>>imani '>{ i meg <br /> e .ted` ige `'«> << < <i <>>`<' i`<``' >< pmg. ' << > < « <>>>}> <> < < _€1 < `< >` <br /> :>:<s:::<:>:<:::>:>:::z:><z<:i's's'::i:?::?`??':"•::isd:isr,?2:;;isii::i>::>::;::>»>:::>:�:»>:z::::<: .. ..:::. : :.. :.. :::: :. : . . .::::::::::: .,:::::::::::.::::: <br /> pi=actor.+:iamblin �rtisniBoat..........:.........:::: :.�::::::�::.:.� ::......:...........::..:.....................::.::: <br />