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Minnesota Lauffiil Gambling <br />Premise Permit Application - Part 2 of 2 <br />7nr <br />K Bank Aooouni Numbar <br />fi,nt hLinA_____________0<y?>l-^l9 <br />Ci^ Staia Zip Coda <br />v\< » irv^ l <br />SfRCC^ fJlciuSf«tf»e/ /-n. f^ond fe7dCrt^/[v\Q >^flLrvac^j«^ <br />0 mir^lObi£/h^ fk'iict^ If^ll/d Am/J <br />'TjALn L>5^/^ fi\nr)rlj^aL ^/m^ri /4^av/ <br />>n-n:iirrinn_ AatliorlaBtloa <br />I htraby oonMni that beat law antoicamant offioars. tha <br />bcMid or agania of tha board, or tha oommitaionar of <br />ravanu# or puMk: aafaly. or aganta of tha oommiaaionara. <br />nuqr antor tha pramiaaa to anlorca tha law. <br />Bask Raeordls Infonnation <br />Tha beard ia autVirIzad to inapaet tha bank racorda of tha <br />gambfing aooouta whanavar naoaaaaiy to fulfill <br />raquirafnania of currant gambling rulaa and law. <br />Oath <br />tdadarathat: <br />•I hava raad thia application and all information aubmittad <br />to too board la true, aocurata and oomplata: <br />•al elhar raqubad bdermation haa baan fully diadoaad: <br />•I am tha chiaf axacuthra offioar of tha organization; <br />*1 aaauma fuR raaponaibility for tha fair and lawful opara* <br />tion of all activitiaa to ba conductad; <br />•I will familiariza myaalf with tha lawa of Minnesota <br />govarning lawful gambling and rules of tha board and <br />agree, if Roansad, to abide by those laws and rules, <br />including amendments to them; <br />•any changes in application information will ba submitted <br />to the board and lo^ unit of government within 10 days <br />of the change: and <br />•I understand that failure to provide required information <br />or providing false or misleading information may result in <br />the denial or revocation of the license. <br />Date <br />\ 1 g if f r rir <br />1. The dly *muat sign this application M tha gambling pram ­ <br />iaaa is toctoad wthin dty Umlta. <br />2. Tha oounly**AND township** must sign this application if <br />tha gambling pramiaaa la locatad within a township. <br />3. Tha tocal unit govammanl (dty or county) must pass a <br />resolution spec' iHy approving or denying this application. <br />4. ^^gy^{Jf]fjgpal unit of governmanfs resolutton ao- <br />nitwing tht« anniieation must he attached to this anplication. <br />5. If this application is denied by tha local unit of government. <br />It should not be aubmittad to tha Gambling Control Board. <br />Township: By signature betow. tha towrtship acknowladgas <br />that tha organization is applying for a premises permit within <br />township iimits. <br />CUV* Of County**Townshfo** <br />IMia: <br />1711 W. Caawt y Bead ■ <br />Mils LC214(Pan 2)