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-2- <br />Minnesota Charitable Gambling Control Board <br />GAMBLING LICENSE APPLICATION <br />(Class A, B, or C) <br />GAMBLING SITE AUTHORIZATION <br />By my signature below, local law enforcement officers or agents of tl-e Board are hereby <br />authorized to enter upon the site, at any time gambling is being conducted. to observe <br />the gambling and to enforce the law for any unauthorized game or practice. <br />BANK RECORDS AUTHORIZATION <br />Ry my signature below, the Board is hereby authorix.ed to inspect the bank records of the <br />General Gambling Bank Account whenever necessary to fulfill .-equirements of current gamblinc <br />rules and law. <br />OATH <br />T her.bv declare that <br />1. 1 have read this application and 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 <br />conducted; <br />6. I will familiarize myself with the laws of the State of Minnesota respecting gambling <br />and rules of the Board and agree, if licensed, to abide by those laws and rules, <br />including amendments thereto. <br />Official, legal Name of Organization <br />Signature (Must be signed by Chief Executive Officer) <br />Title <br />Date <br />ACKNOWLEDGEMENi OF NOTICE BY LOCAL GCVEn NING :;COY <br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I <br />admit having been served with notice that this application will be reviewed by the <br />Charitable Gamb'ing Control Board and if approved by the Board, will become effective 30 <br />days from the date of receipt (noted below), unless a resolution of the local governing <br />body is ;dosed which specifically disallows such activity and a copy of that resolution is <br />received by the Charitable Gambling Control Board within 30 days of the below noted date. <br />LOCAL GOVtRNING BODY <br />Name of local Governing Body <br />Signature of Person Receiving Application <br />ORGANIZATION <br />Date Received (This is date from which the 30 day Name of Representative for Gambling License Applicant <br />approval begins) (serving notice) <br />M-00001-01 (12/84) Fite - Board Canary - Board Pink - Applicant Goldenrod - Governing <br />(data entry) Body <br />