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Minnesota Lawful Gambling Premise Permit Application - Part 2 of 2 �;::;::':::'s::':%�:: Gambitnci Ba1nk Account n' m :.:. ....:.. ....:..:_....: :... ...:.,...:.:........_ .:......>.:..:::.:... Bank Name //��Name Bank Account Number Bank Address C cvcity tats p � /� I . / G J' i/��tl�ie� V I'YT.✓ ��Y/� ;: >:::.::. :.::N address,.and�fs of............:autharizeJms9 . :::.::::.::::::.:.::..:::.::: ...........::.:. ::arr!a,::.::.:..:::::..::..::::::::::.....p soRS;;::.;::.;;.;:.................... ...:... .:.:..,:.... ..:... :.::...:.:._:::.::::::.::::::.::::..:.:.:.....::::::::::::.: .:::::.,:::::::::::::. :...:.:.:.:......:....:.::::...::::::::.::.:::............................Oryarruatron'streasurmr.mattaofara aarr►b6ny `—Name Address live ou �/�C ir—F- Oti1 rc p�9 y -2,2P"4 A✓G PE tr r, A/SI 4_s o .;� wiled eat .... .. ...................... ...:.... .....:........ .. :.::...................:.:;:.:::::.::r.v.:.r;.:;.::.;:;.. GambUng Site Antho on •1 am the chief executive officer of the organization; I hereby consent that local law enforcement officers,the •1 assume full responsibility for the fair and lawful opera- board or agents of the board,or the commissioner of tion of all activities to be conducted; revenue or public safety,or agents of the commissioners, .1 will familiarize myself with the laws of Minnesota may enter the premises to enforce the law. governing lawful gambling and rules of the board and Bank Records Information agree, if licensed,to abide by those laws and rules, The board is authorized to inspect the bank records of the including amendments to them; gambling account whenever necessary to fulfill -any changes in application information will be submitted requirements of current gambling rules and law. to the board and local unit of government within 10 days • Oath of the change;and 1 declare that: •1 understand that failure to provide required information •1 have read this application and all information submitted or providing false or misleading information may result in to the board is true, accurate and complete; the denial or revocation of the license. -all other required information has been fully disclosed; Signature of chief executive officer Date .....:..:...:.:............:............:.:..:.....::.:.............:..:....:...................................... : ocai.Government Acknowiedgemert. :.::;;:.;:.:........:.:::....<.::• ...:.:. 4. A copy of the local unit of government's resolution ap- proving The city*must sign this application H the gambling pram- proving this application must be attached to this aoolication. ices is located within city limits. 5. ff this application is denied by the local unit of government, 2. The county"AND township"must sign this application if it should not be submitted to the Gambling Control Board. the gambling premises is located within a township. 3. The local unit government(city or county)must pass a Township: By signature below,the township acknowledges resolution specifically approving or denying this application. that the organization is applying for a premises permit within township limits. CI • or County" Township** City or County Name Township Name Signature of person receiving application , Signature of person receiving application 1 I Title I Date Received Tide I Date Received Reber to the instructions for required attachments. Mail to: -Gambling Control Board RosewoodPWU South,3rd Floor 1711 W.County Road B Roseville,MN 55113 LG214(Part 2) (aw?r2svi)