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Charitable Gambling Control Board
<br />Rm N-475 Griggs-Midway Bldg.
<br />1821 University Ave.
<br />St. Paul, MN 55104-3383
<br />(612) 642-0555
<br /> GAMBLING LICENSE RENEWAL APPLICATION
<br />
<br />LICENSE NUMBER:
<br />
<br />For Board Use Only
<br />Paid Amt:
<br />Check No.
<br />Date:
<br />
<br />~,-~l?J3-t~! / EFF. DATE: ~lJ2218f; I AMOUNT OF FEE: ~'~ [~'~, ~
<br />
<br />1. Applicant-Legal Name of Organization 2. Street Address
<br />LIOl(~ CL[Ig I~,~r¥ P~ I~ 77!
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<br />3. City, State, Zip 4. County 5.
<br />
<br />6. Name of Chief Executive Officer 7.
<br />l~tgh lundber9 (
<br />8. Name of Treasurer or Person Who Accounts for Revenues 9.
<br />P~t ~0r0ff (
<br />
<br />10. Name of Gambling Manager
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<br />13. Name of Establishment Where Gambling Will Take Place
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<br />16. Lessor Name
<br /> SJ$ !I~C
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<br />11. Bond Number
<br /> 325~86
<br />
<br />14. County
<br /> Anok~
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<br />Business Phone
<br />Business Phone
<br />
<br />Business Phone
<br />612 )
<br />
<br />12. Business Phone
<br /> (~2) ,~3-,~
<br />15. No. of Active Members
<br />
<br />17.
<br />
<br />Monthl~ Rent:.
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<br />18. If Bingo will be conducted with this license, please specify days and times of Bingo.
<br /> Days Times Days Times
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<br /> . 19. Has license ever been: [] Revoked Date:_
<br />.... '~201 Have internal controls been submitted previously?
<br /> 21. Has current I~ase been filed with the board?
<br /> . 221 ~as current sketch been filed with the board?
<br />
<br /> Days
<br />
<br />[] Suspended Date: [] Denied Date:
<br />
<br /> [] Yes ~ No (If"No," attach copy)
<br /> H
<br />
<br /> [] Yes ~. No (If"No," attach copy)
<br /> [] Yes No (If "No," attach copy)
<br />
<br />Times
<br /> \
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<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 time, gambling is
<br />being conducted, to observe the gamblir[g 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 General Gambling Bank Account whenever necessary to
<br />fulfill requirements of current gambling rules and law.
<br /> OATH
<br />I hereby declare that: ': '.
<br />1. I have read this application and all information submitted to the Board;
<br />2. Ali 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 all 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 licensed, to abide by those
<br /> laws and rules, including amendments thereto.
<br />
<br /> 23. Official Legal Name of Organization I Signature (Chief Executive Officer) Date Title
<br /> Cuu, ..x" / ' ,-/
<br />
<br /> ACKNOWLeDGemenT OF NOTIO~ BY LOOAL, GOVERNING BODY
<br />. I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been se~ed with notice that this application will
<br /> be reviewed by the Charitable Gambling Control Board and if approved by the Board, will become effective 30 days from the date of receipt (noted
<br /> below), unless a resolution of the local governing body is passed which specifically disallows such activity and a copy of that resolution is received by
<br /> the Charitable Gambling Control Board within 30 days of the below noted date.
<br />
<br />24..City/County Name (Local Governing Body) Township: If site is located within a township, please complete items 24
<br />/--~i/' '[ < ~ L..," t;i,,{ l\,,,j/ and 25:
<br />Signatu,re of Person Receiving Application: 25. Signature of Person Receiving Application
<br /> ' !y .... , /';:.', .~":.'~
<br /> ~'~z-~./~..~,:...._ ' .... ~:'~6:,.~, .'._.c:.,~z:.:.... -.
<br /> Title:
<br />
<br />TRI~--- // Date Received (this (:Jctte begins,30 day period)
<br /> r' J:¢r;'. ,..:'.,.'x' ,~. ~, ~..;~ , ,; ...5 .,- ,:_, 7
<br />Naroe of Person Delivering App!ication to Local Governing Body:
<br />../ F__. , ,-fl. rv't u.e-.-'T
<br />
<br />Township Name
<br />
<br />CG-00022-01 (5/87)
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<br />White Copy-- Board
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<br />Canary--Applicant
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<br />Pink--Local Governing Body
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