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MINNESOTA LAWFUL GAMBLING <br />LG230 Application to Conduct Off -Site Gambling <br />ORGANIZATION INFORMATION <br />10/24 Page 1 of 2 <br />No Fee <br />Organization Name: A,o(4 gq,.7 License Number: C/80V? <br />Address: I" City: A itaW# MN Zip: / 7 %d <br />Chief Executive Officer (CEO) Name: I /1 4714 092 Daytime Phone: b a- <br />Gambling Manager Name: <br />V <br />GAMBLING ACTIVITY <br />Daytime Phone: ,41/7 6-ev —5-6 <br />Twelve off -site events are allowed each calendar year not to exceed a total of 36 days. <br />From to <br />Check the type of games that will be conducted: <br />Raffle <br />Pull -Tabs <br />Bingo <br />Tipboards <br />Paddlewheel <br />GAMBLING PREMISES I /� <br />Name of location where gambling activity will be conducted: �{( 1/4ri )29Old G/ al/ ^ ‘07//> <br />Street address and �7/ /j/ �) z /� %�G <br />City (or township): Sf yone 5 5f ��% 4 �"f/ Zip: 5303 County: / 'ty)g <br />• Do not use a post office box. <br />• If no street address, write in road designations (example: 3 miles east of Hwy. 63 on County Road 42). <br />Does your organization own the gambling premises? <br />Yes If yes, a lease is not required. <br />Ir l No If no, the lease agreement below must be completed, and signed by the lessor. <br />LEASE AGREEMENT FOR OFF -SITE ACTIVITY (a lease agreement is not required for raffles) <br />Rent to be paid for the leased area: <br />(if none, write "0") <br />All obligations and agreements between the organization and the lessor are listed below or attached. <br />• Any attachments must be dated and signed by both the lessor and lessee. <br />• This lease and any attachments is the total and only agreement between the lessor and the organization conducting lawful <br />gambling activities. <br />• Other terms, if any: <br />Lessor's Signature: Date: <br />Print Lessor's Name: <br />CONTINUE TO PAGE 2 <br />