|
Gambling License Application
<br />Type of Application: [~Class A I-)Class B [-IClass C ~Class D
<br />I~Yes eno 22. Is gambling premises located within city limits?
<br />{~YeeDNo 23. Are allgambling activities conducted at the premises listed in #18 of this application? If not, complete a separate
<br /> application for each premises (except raffles) as a separate license is required for each premises.
<br />OYes [~No 24. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year, and
<br /> attach a sketch of the premises indicating what portion is being leased. A lease and sketch are not required for
<br /> Class D applications.
<br />25. Amount of Rent Per I 26. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions.
<br /> Month or Bingo Occasion Day Time Day Time Day Time
<br />
<br /> I I' $ '--L~C"~, ~',C?' % .'., e' ,., , ,, :' · ,',.. ~ .,-
<br />
<br />~Yes ,r-:No 27. Has the $10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?
<br />
<br />28. Insurance Company Name (not agency name)
<br /> Federa! Insurance Company
<br />
<br />3j~.:[ Lessor Name
<br /> ke Hed~na
<br />
<br />31. Address
<br /> 1220 27th Ave
<br />
<br /> NE 55418
<br />33. Gambling Manager Name 34. Address
<br />Pau] ScnIezcher
<br /> 1377 Sigfr~d 55123
<br />
<br />29. Bond Number
<br /> ,o,~ ~ ~- 17_7r,_¢
<br /> 32. City, State,Zip
<br /> Mpls., MN
<br /> 35. City, State, Zip
<br /> ~aaan.
<br />
<br />36. Gambling Manager Business Phone 137.
<br /> (.512)871-0462
<br /> I
<br />
<br />Date gambling manager became
<br />member of organization:
<br />
<br />Month 6 Year
<br />
<br />OYes [~No 38. Has the license termination form been completed? Attach copy.
<br />l-lYes [~No 39. Has the compensation schedule been approved by the organization? Attach copy.
<br />
<br /> 40. List the day and time of the regular meeting of the organization. Day Time
<br />41. Bank Name 42. Bank Address I 43. Bank Account Number
<br /> I
<br /> GAMBLING SITE AUTHORIZATION
<br />By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site at any
<br />time gambling is being conducted to observe the gambling and to enforce the law for any unauthorized game or practice.
<br /> BANK RECORDS AUTHORIZATION
<br />By my signature below, the Board is hereby authorized to inspect the bank records of the gambling bank account whenever
<br />necessary to fulfill requirements of current gambling rules and law.
<br />
<br />I hereby declare that: OATH
<br />1. I have read this application and all information submitted to the Board;
<br />2. All information submitted is true, accurate and complete;
<br />3. All other required information has been fully disclosed; ~.
<br />4. I am the chief executive officer of the organization; ~
<br />5. I assume full responsibility for the fair and lawful operation of alt activities to be conducted;
<br />6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree, if
<br /> licensed, to abide by those laws and rules, including amendments thereto;
<br />7. Membership list of the organization will be available within seven days after it is reauested by the board.
<br />44~ Official, Legal Name.of Organization.. 145. Signature (must be signed by Chief Executive Officer)
<br />
<br />Title of Signer j Date
<br /> I
<br />
<br /> ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice that
<br />this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will become effective
<br />60 days from the date of receipt (noted below) unless a resolution of the local governing body is passed which specifically
<br />disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 days of the
<br />below noted date.
<br />
<br />46. Name of?~..or County (Local Governing Body) If site is located within a township, item 47 must be completed, in
<br />/. addition to the county signature. If township is not organized,
<br />..' ,, '_,:. ,; .i'_~::.~ ' ~. county must sign.
<br />Signature of person receiving application 47. Name of Township
<br />
<br /> ~ , . ,'. .. ~ ,_.; ........ ~ -- ,
<br />
<br />Title Date received (60 day period
<br /> begins from this date)
<br /> ., '.' ,,.. ... .~.. ?',"~.. · ,,, ,' ., ,1,~ ~
<br />48. Name of person deliveridg application to Local Governing Body
<br /> ,.",> ,,'~ /
<br /> ,~-,. ~: ,., 1~., L,.../'~.~.~,4
<br />
<br />CG-0001-03 (8/88) White Copy-Board
<br />
<br />Signature of person receiving application
<br />X
<br />
<br />Title
<br />
<br /> Canary-Applicant Pink-Local Governing Body
<br />
<br />Page 2 of 2
<br />
<br />
<br />
|