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Minnesota Lawful Gambling <br />LG230 Application to Conduct Annual Off-Site Gambling <br /> <br /> Page 1 of 2 <br /> 3/01 <br />No Fee <br /> <br />Licensed Organization/~n, formation (please~j ~/print all iaformation) <br />Organization Name L~_~__~.'~ License Number (5 digits) <br />L~cense' Expiration --Date _~__/~_/__~~ ......... 7 ..... -~ / ........ ~ <br /> Class of Organization License (A,[B) C, or D) <br /> ~,, i/ I~)~ L Daytime Phone~ <br />Name of Chief Executive Officer ~l ~ ~L~~ Number ('~) ~/ <br />(Do not list the gambling manager) <br /> <br />Gambling Premises Information <br />Name of establishmentJfunction where gamb,ing activity wil, beconducted_~,t ~ ~i~].~ ~' ~I~ ~.~-'~ <br /> <br />(Do not use a post office box. If no street address, write in the road designations. Example: 3 miles east of Hwy. 63 on County Road 42) <br /> <br />[.ease Requirement. Does your organization own the gambling premises? <br /> [-~ If yes, no lease is required. <br /> ~ If no, a lease agreement must be attached (you~may use lease form LG224, available from the Board). However, no lease is required if the <br /> only gambling a~tivity to be conducted is ~ <br /> <br />Date(s) for off-site activity up to 12 consecutive <br />days: <br /> Begin date __~ /_.J..~O_l ~)__~ <br /> End date ~,, / /~ / ~w~) <br /> <br />Type of Gambling Activity. Check the box(es) for the <br />gambling activity your organization will be conducting. <br /> <br />Puli-Tabs [-'-] Bingo F--I Tipboards <br />Raffles ~ Paddlewheels <br /> <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises is within city limits, the city must sign this application and provide a resolution. <br /> <br />On behalf of the city, I acknowledge that this application <br />will be forwarded to the appropriate city officials, the city <br />must pass a resolution specifically approving or denying <br />this application, and a copy of the resolution will be <br />forwarded to the applying organization. <br /> <br />(Signature of city personnel receiving application) <br />Title ~ ~ ~(~/~- Date l'g) I~,,.flu~ <br /> <br />If the gambling premises is located in a township, both the county & township must sign this application. <br />The county must provide a resolution. <br /> <br />For the township: On behalf of the township, 1 <br />acknowledge that the organization is applying for an <br />annual off-site gambling activity within the township <br />limits. <br /> <br />A township has no statutory authority to approve or <br />deny an application (Minn. Stat. 349.213, subd. 2). <br /> <br />Print name of township <br /> <br />(Signature of township official acknowledging application) <br /> <br />Title Date / <br /> <br />For the county: On behalf of the county, I acknowledge <br />that this application will be forwarded to the appropriate <br />county officials, the county must pass a resolution <br />specifically approving or denying this application, and a <br />copy of the resolution will be forwarded to the applying <br />organization. <br /> <br />Print name of county <br /> <br />(Signature of county personnel receiving application) <br /> <br />Title Date <br /> <br />/ / <br /> <br />Chief Executive Officer (CEO) Acknowledgment and Oath <br />I have <br /> read <br /> t~rmatio~s'~'~rue,~ccurate, and complete. I hereby authorize the Gambling Control <br />Board to mo~~f.~n~F,~n Zn~b~.2 <br /> tent with the class of permit being applied for. <br />CEO Signature ~'~-~'~- '~,,~"~ Date ?//~'/~,~L- <br /> <br /> <br />