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LG230 <br /> <br />Miata I,~! Gmn. bZtng <br /> <br />Application for One-Day <br />Off-Site Lawful Gambling <br /> <br />For Board us~ only <br />Bas~ License # <br /> <br />Name of Ch~el Execubve Off, cer (plea.r,e print) Pt,one Number <br /> <br />~. Name o[ Iocat~n where of/-site gambling will be held <br />2. Addr~r~ ~f off-~te iocabc~ ~-. Ciw ~towr~hip St~le Z~p~ C,ooe <br /> <br />4. Has ),our organization conducted off-site gambling ~is c.a.tend~ year? <br /> <br />Yes ~ No II ye~,, what w~ ~ date ot ~ne <br /> eve1'qt? <br /> <br /> / / <br /> <br />I affirm that the above intormation is b'ua ar~ correct. <br /> <br /> Date <br />Sio. na~re of Chief Executive Off'x::e~ ] ~ ~ ~ ~ . <br /> <br />2. ~e ~ AND townshio must sign ~is ~pI~gon ii ~e gamb~ ~mi~ is 1~ ~in a ~wnship. <br />3. ~e b~i unit of gov~m~t (d~ or ~n~) must <br />4. A ~ of ~eJ~l unit of <br />6. If ~is appli~fion is ~ by ~ ~1 unit of govemm~L it s~uid not ~ submi~ to ~ ~bling C~ ~. <br /> <br />Ctty or County Township <br /> Township name <br /> <br />Signature cf p~rson receiving application <br />Title Date received <br /> <br />is township: .. ,C~r~a.rlLZed, Unorganized ~Unincerporated <br /> <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 Ptaza South, 3rd Floor <br /> 1711 W. County Road B <br /> RosevJlle, MN 55113 <br /> <br />//--5/ <br /> <br /> <br />