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,, Gambling License Application
<br />~ Type of Application: ~Class A r-]Class B [~Class C
<br /> ~Yes E~No 23. Is gambling premises located within city limits?
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<br />FlClass D
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<br />Page 2
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<br />.~..Yes DNo 24. Are all gambling activities conducted at the premises listed in # 19 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 />~Yes [~,No 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. 26. 27.
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<br />DYes ~No
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<br />Does the organization lease the entire premises? If no, attach a sketch of
<br />the premises indicating what portion is being leased. A lease and sketch
<br />is not required for Class D applications.
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<br />Amount of Monthly Rent , -.
<br /> $ l~j ,,--/-~ ~_~ ~C-.3 :'/'-'I'"
<br />I u"'d *', .'
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<br />~,,Yes E]No 28.
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<br />Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions:
<br /> Time~
<br />°"Yl f
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<br />]~es ~No 29. Has the $10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained? Attach copy of bond.
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<br />30, Insurance Comp~qny Name . ,~ ~ 131. Bond Number
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<br />32+ Lessor Name ~33, Address / ~ . ~34. City State Zip ' ..
<br /> ' ' ~ ~ ~ ' ' /' 1 ' ~)'~ ' / ~ " - ,
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<br />35. Gamblin~Ma~gerName 36. Address . , ~b 37. City, State, Zip
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<br />38, Gambling Manager Business Phone 139, Date gambling manager became / '
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<br /> GAMBLING SITE AUTHORIZATION
<br />B~ my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site,
<br />at any time, gambling is being conducted, to observe the gambling and to enforce the law for an~ unauthorized game or
<br />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
<br />whenever necessary to fuffill requirements of current gambling rules and law.
<br /> OATH
<br />I hereby declare that:
<br />1. I have read this application a'nd 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 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,
<br /> if licensed, to abide by those laws and rules, including amendments thereto,
<br />40. Official, Legal Name of Organization 41. Sig0eture (must be signed by Ch[e~ Executive Of[Jcer) ~
<br /> ,7 , .,..,; .:'d . I .
<br />
<br />Title
<br /> of
<br /> Signer~
<br /> : i ' "
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<br /> ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I hereby acknowledge receipt of a copy of this applicatiom By acknowledging receipt, I admit having been served with
<br />notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will
<br />become effective 30 days from the date of receipt (noted below), unless a resolution of the local governing body is passed
<br />which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control
<br />Board within 30 days of the below noted date.
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<br />42. Name of City or County (Local Governing Body) If site is located within a township, item 43 must be completed, in
<br /> · ,,. addition to the county signature.
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<br />Signatur. e Of person re.c. eiving applic.a,.tio, n 43. Name of Township
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<br />Title
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<br />Date received (30 day period
<br />begins from this date)
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<br />~-4. Name of Person delivering application to Local Governing Body
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<br />Signature of person receiving application
<br />X
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<br />Title
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<br />CG-0001-02 (8/86) White Copy-Board Canary-Applicant
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<br />Pink-Local Governing Body
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