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� Fee: �10:Q0 <br /> �„O�O Da�te Received: _ . _ <br /> � Re��ipt�#: _...-- <br /> � � <br /> �.�f� 1 <br /> L <br /> `9KfSH��� City of Orono <br /> Application for Gambling Activity <br /> � � :.2�` � ' ^. .. � _ -_ , . r . �=�Y�ti,__��,f. :�...+..;�.��Ls����r.. �. � swi, ,'r -,K• .' <br /> �2ypedf-Permit-r � .. • " . `Ty:.pe,`of��an�,kiling_Activity:- _ <br /> • Premises Renewal • Bingo <br /> Effective Dates: • Paddlewheels <br /> • Pull-Tabs <br /> • One-Day Lawful Gambling Exempt • Raffle <br /> Effective Date: ��O�CI�,xU► "�� �J• Tipboards <br /> Name of Event: �( 1� <br /> Organization: �(�,1(� �t�('(1��(��),�.,� �a <br /> Address: <br /> Phone: ��9 . ^ ����] T Y'�° 'G �. <br /> Applicant: �p� <br /> Affiliation with Organization: ���' � �r <br /> Address: ���� �K � �� l ���C'' d. �C�RN . 3� � <br /> Phone:�Q5I'3 $'-' �-1()()S <br /> Email: �'6�j�'(1.�0.��7�Q� t.:�',�• CC��(Y1 <br /> Establishment Where Gambling will be Conducted: � <br /> Address: �► Y <br /> Property Owner: <br /> Gambling Manager: <br /> ��^�� _(first� (middle) (last) <br /> Phone: <br /> Name/Description of Event: 1 � � <br /> �'a , <br /> D (s) of Operation: d��j <br /> Hours of Operation: ,�:(� - �{,: <br /> Required Submittals: <br /> • Copy of permit application from the Minnesota State Gambling Control Board <br /> • Sketch plan of area being leased for gambling activity <br /> The Orono Chief of Police shal]have 30 days in which to investigate and make a recommendation. The undersigned applicant <br /> hereby agrees to the conditions quot ec 'on 3 31 of t Or no City Code and any additional City staff requirements. <br /> Signature of applicant: Date: (Z` �.7 " �� <br /> For Office Use Only <br /> Review by Administration: � Approved ❑ Denied ❑.NA By: Date: <br /> Review by Police Department: ❑ Approved ❑ Denied ❑ NA By: Date: <br /> 2750 Kelley Parkway,P.O.Box 66, Crystal Bay,MN 55323 <br /> Phone: 952-249-46G0/Fax: 952-249-4616/www.ci.orono.mn.us <br />