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Minnesota Charitable Gambling Control Board <br /> <br />GAMBLING LICENSE APPLICATION <br /> (CLass A, B, or C) <br /> <br />GAHBLZNC SITE AUTHORIZATION <br /> <br />By my algnltute be]ow, loci] law enforcement officers or agents of the Board ire hereby <br />authorized to enter upon the iii'e, at inY time gambling ia being conducted~ to observe <br />the gambling and to enforce the llw for Iny unluthorized game CT praCtiCe. <br /> <br />BANK RECORDS AUTHORZZATION <br /> <br />By ey signature below, the Board ie hereby luthorized to inspect the bank records or the <br />Genera! Gaebling Bank Account whenever necessity to fulfill requireaentl of current glmblin~ <br />rules end ~aw. <br /> <br />OATH <br /> <br />I hereby declare that <br /> <br />I. I have zesd this application and ell information submitted to the Board; <br />2. All information submitted is true, accurate, end complete; <br /> all other required information has been fully disclosed; <br />a. 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 <br /> conducted; <br /> I will familiarize myself mith the lama of the State of flinneeoti respecting gambling <br /> and tulsa of the Board and igtee, if licensed, to abide by those ]imm end tulsa, <br /> including amendments ~thereto. <br /> <br />Official, [egsl Name of Organization <br /> <br />Signature (f~st be signed by ~hief Executive Officer) <br /> <br />Title <br /> <br /> )ate <br /> <br />ACKNOYLEDGER£NT OF NOTICE BY LOCAL GOVERNING BODY <br /> <br />I hereby acknowledge receipt cf I copy of this application. By'acknowledging receipt, l <br />admit having been served llth notice that this application will be revealed by the <br />Charitable Gambling Control Board and if approved by the Board, will become effective }0 <br />days from the date of receipt (noted below), unless · resolution of the local governing <br />body ts passed which specifically disslloea such activity end · copy of that resolution la <br />received by the Charitable Gambling Control Board within ~O dsya of the below noted date. <br /> <br />LOCAL OOVERNtN§ BODY <br /> <br />~Name of Local Governing Body <br /> <br />Signature of Person Receiving Application <br /> <br /> Date Received (This ie date from ~hich~the ~0 day <br /> <br />~O01-Ol (12/~) ~ite - ~rd ~ry - Board <br /> (~ta entry) <br /> <br />ORGANIZATION <br /> <br />Name of Representative for Gambling License Applicant <br />{serving notice) <br /> <br />Pink - Applicant <br /> <br />~oldenrod- ~overning <br /> Body <br /> <br /> <br />