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11111121, 7:21 AM <br />Revize Online Forms <br />By submitting this application, I affirm that the facts set forth are true, correct and complete. I understand that any false or misleading statements, omissions or other misrepresentations <br />made by me on this application may result in revocation of the premise permit. I assume full responsibility for the fair and lawful operation of all lawful gambling activities to be <br />conducted in the City of Mounds View. The organization and I will comply with the Mounds View City Code, Rules of the Minnesota Gambling Control Board, and Minnesota Statutes <br />governing lawful gambling activities. I certify that the Gambling Manager is bonded and licensed as required by Minnesota Statutes. <br />APPLICANT MUST BE SOMEONE LISTED (ABOVE) ON THIS APPLICATION <br />* Applicant First MI * Applicant Last <br />Marcie K DeMaio <br />* Email * Applicant Signature <br />mdemaio87@outlook.com Marcie DeMaio <br />Format: MM/DD/YYYY <br />Background Check form and color copy of current drivers license or ID (front and back) required for Gambling Manager. <br />Chapter 111, Lawful Gambling, Mounds View City Code. <br />Upload a File (Additional Information/Forms/Copy of Drivers Upload a File (Additional Information/Forms/Copy of Drivers <br />License or I D License or I D <br />Choose File No file chosen Choose File No file chosen <br />$100 Investigation Fee TO PAY CLICK HERE <br />0 Proof of Gambling Manager State license <br />Completed informed consent/background check form for Manager <br />0 Completed Form LG214 Premises Permit Application <br />Completed Form LG215 Lease for Lawful Gambling Activity <br />0 Color copy (front and back) of Manager's driver's license <br />0 Read Chapter 111, Lawful Gambling, Mounds View City Code <br />Submit completed Mounds View Premises Permit Application (this form) <br />Pay $100 Mounds View investigation fee <br />https://moundsviewmn.rja.revize.com/reports/179446 3/3 <br />