Laserfiche WebLink
'1 <br /> ! <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />LG230 <br />(S/2/91 ) <br /> <br />Minnesota I~_ .,flzl Gambling <br /> <br />Application for One-Day <br />Off-Site Lawful Gambling <br /> <br />For Board use only <br />Base License # <br /> <br />~;;i'~;;~i;;~ ~ j ~eNum~ __ I License number J Expiration Da~e <br />Address (s~ ~t o~ ~x[num~r) <br /> <br />CiD~ Zip ccxte <br />Name of Chief Execulive Officer (please print) Phone Number <br /> <br />1. Name o! Iocatiol;, rWh~e o!f-kite gambling will be held <br />2. Adarer, s of 5{~:~rt,~ Ic;llalion. . City or township State Zip Code <br /> <br />4. H~ your org~iza6~ ~duct~ off-site gam~ing~ ~nd~ ye~? ~ Yes ~No It yes, what w~ ~e date of ~ event? <br /> / / <br /> <br />I <br />I <br />I <br />I <br /> <br />I affirm that the abo~e [nform~atJon is true and correct <br />Signature of Chief ~:~tive ~;)ffi.cer ._ ~ , ,, Date <br /> <br />"i'.' '~e ;ity 'r~us{ si~lfi 6i~r'aPl~licalior~ 'i'f the gambling premiles is Io<~at~'within city limit~i ........................................................................................... <br /> <br />2. The countv AND ~ must sign this application if the gambling premises is located within a township. <br />3. The local unit of, g0~vemm~ent (city or county) must pass a resolution specifically approving or denying this application. <br />4. A coDY of the local finit of ~3ovemment~s resolution aonrovino this aoolicatien must be attached to this aoolicafion. <br />6. If this application is ~lenie~ by the local unit of government, it should not be submitted to the Gambling Control Board. <br /> <br />I <br />I <br />I <br /> <br />I <br />I <br />I <br />I <br /> <br />City or County ~ Township <br /> ~ Township name <br /> <br />City or county name ~ ..,_, : _ ~ <br /> <br />Sig.da~re of person ~a~eiving a,~pli~a~z., <br /> <br />Title~ . ~ ,~ : Date received <br /> <br />Signature of person receiving applical~on <br /> <br />Title Date received <br /> <br />Is township: __.Organized Unorganized Unincorporated <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 Centre[ Board <br /> Rosewood Plaza South, 3rd Floor <br /> 1711 W. County Road B <br /> Roseville, MN 55113 <br /> <br /> <br />