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Minnesota Lawful Gambling <br />Organization License Application, LG200 A - Part 2 <br /> <br />Please tist the lawful purpose expenditures for which your organization will expend gambling funds, (Refer to Minn. Statute <br />349.12 Subd.12.) Give specific examples. <br /> <br />Name of organization's gambling manager Address City State 'Zip Code <br /> <br />List other activities through which your organization raises funds. <br /> <br />What percentage of your organization's funds are raised or will be raised through lawful gambling? <br /> <br />What other activities does your organization engage in (not fundraising activities)? <br /> <br />I declare tha~: <br />· 1 have read this application and all information submitted to the board; <br />· All information is true, accurate and complete; <br />· All other required information has been fully disclosed; <br />· t am the chief executive officer of the organization; <br />· t assume full responsibility for the fair and lawful operation of all activities to be conducted; <br />· I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the board and agree, <br /> if licensed, to abide by those taws and rules, including amendments to them; <br />· A membership list of the organization will be available within seven days after it is requested by the board; <br />· Any changes in application information will be submitted to the board and local government within 10 days of <br /> the change; and <br />· A termination plan will be submitted to the board within 15 days of termination of all premise permit(s). <br />· I certify that the gambling manager is bonded and licensed as required per Minnesota Statute. <br />, Failure to provide required intormation or providing false or misleading information may result in the denial or revocation of <br /> the license. <br /> <br />Signature of Chief Executive Officer Date <br /> <br /> I <br />Refer to the ~nstructlons for the required attachments. REMINDER: The organization's chief executive officer and <br />treasurer must complete the Organization Officer Affidavit, form LG200B. <br /> <br />Mail to: <br /> <br />Department of Gaming - Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Roseville, MN 55113 <br /> <br />I <br />i <br /> <br />I <br />I <br />I <br /> <br />I <br />I <br />I <br />! <br /> I <br /> <br /> <br />