Agenda - Council - 06/10/2003 - Laserfiche WebLink

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gS/g3/2B03 g8:25 5514539274 CLIMB THEATRE PAGE LG214 Premises PermitApplicatlon Bingo Occasions for Class A or C Permits Page 2 of 3 7/01 I I I I I I I I I I I I I I I I I If appyng for a clas~ A or C permit, enter day and beginning/ending hours of bingo occasions (indicate A,M. or P.M,), No mom {h~n ~n bingo o~s~ons may be ~ducted per we~. An ~cas[on must be et least one and one-half bourn, not to exceed four bourn. ~ Beginnl~/Endin~ Hours Day Be~innin~/~in~. HOU~ ~ Bg~lnnin~lEndinq Houm to to to to to __ to to Noon Hour B~go Only Day B~e~inninq/Endin~ Beginoh3q/Endin~l Ho0r8 ~ Be~innl0g/Endinfl .HOUr3 te to Gambling Bank Account Information Bank namejM- ,~ . -- Bank account number*~ ~_ ~_L__O. Ot~mc ~J ~P,~IL 55L~lot 995 * N~ organi~tions: The account number maybe obtainod and ~ubmi~ ~ the Gambling Control Board within ten d~ys o~er you rocoi~ ~ur premi~os permit. Name, address, and title of members auf. horlzed to sign checks from {he gambling account. The omjanizat~n's treasurer may not handle gambling funds. r~ Name Street Address City Zip C~de /X~' le ' "" ' ..... ' ....... -~' " O~' '" ~ ...... ' ' ...... ' ..... Actmowledgment Gambling site authorization ! hereby consent that local law cnfixcemem offic~r~, the ~d ~ agars of the ~rd, ~ the ~missi~ ofr~enue or public sa~W ~ ag~t~ ofth~ commissioners may ~t~ the pr~s~s to ~c~ the Tho board [s authorized to inspect ~he bank the gambling account wh~e~r nv~essa~ to '~lfill r~ulr~ts of ~ent gambling ~les ~d law, Organization license authorization [ hereby auth.otize tim Gambling Control Board to I declare that: l. I have rsad this application and all information submitted to the board is true, accurate, and complete; 2. ali other required information ha~ been fully disclosed; 3. I am the chief executive officer of the orgmaization; 4. I assume full responsibility for lhe fair artd lawf-ul operation of all activities to be co~ducted; 5. I will fanBlia~z~ myself with the laws of Minnesota gov~-rning Izwful gambling and rules of the t~oard and agree, if licensed, to abide by'those laws and rules, including m~ad~ts to them; 6. any changes irt application informaOot~ will be submitted to the board and local unit of governmrmt within ten days modify the class of organization license to be of the cha~lge; and consistent w/th the ciasa ofpremisea [:~rmi,,t bek~g .................. . ~.~l;,~l c~,. ./ ...... .~ I. I llt'IciGrsh3Illl [Ilar Iallllr¢ 110 I)['OYl6~ requLl'eO lrllOt'TllaltOll ~vi, ........ . .... .,: ......... _'~ ~,--/" ,}~:-' ,...,'" -,..-,~ or providing fils= or mis_J,eadigg inforntg~,on mE result .,. '"'"' --.'::7-;:>:: -,,--'-;: ........ ,,/,-~ in the denial or tevoc~on of/the liccn~-eff .... · ..., .-.,....,..:::.:?.~.;,,.--~ .~--~:-~ ~, / _/I I 1 Si9~fiturff~f.~ffa[ ox-o~Utive,.~h~r (E~ig~eo may n~t sion) . ,/ _ Oat, -121-