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Minnesota Lawful Gambling 3/11 Page 1 of 2 <br /> LG214 Premises Permit Application Annual Fee $150 FOR BOARD USE ONLY <br /> Required Attachments to LG214 $ <br /> 1. If the premises is leased, attach a copy of your tease. Mail the application and required attachments to: <br /> Use LG215 Lease for Lawful Gambling Activity. Gambling Control Board <br /> 2. $150 annual premises permit fee, for each permit. 1711 West County Road B, Suite 300 South <br /> Make check payable to "State of Minnesota." Roseville,MN 55113 <br /> Questions? Call 651-539-4000 and ask for Licensing. <br /> I <br /> Organization Information <br /> 1.Organization name L ni rj LA r ua f A 61 A J A License number �;� <br /> 2.Chiefexecutiveo€ficer(CEO) 1 l .y1 a ti s Daytimephone <br /> 3_Gamblingmanager <br /> CZ,L� f �t' s'yI fYl(r v, Daytimephone_1 <br /> Gambling Premises Information <br /> 4.Current name of site where gambling will be conducted I( err � s ,Jta f l <br /> 5. List any previous names forthis location '' <br /> 6.Street addresswhere premises is located I�� tJV ICU" <br /> o rr1 ' <br /> (Do not use a P.O.box number or mailing address) <br /> 7. City Township County Zip code <br /> OR <br /> ! <br /> 8. Does your organization own the building where the gambling will be conducted? <br /> Yes No If no,attach LG215 Lease for Lawful Gambling Activity. <br /> Yes No Raffle only. No lease is required if only a raffle will be conducted. <br /> 9. Is any other organization conducting gambling at this site?Dyes 0No ®Don't know <br /> 10.Has your organization previously conducted gambling at this site?aes[]No <br /> Gambling Bank Account Information(must be in Minnesota) <br /> 11. Bank name Bank account number <br /> I�PSfeiil (.111/ �00I t1S <br /> ` 12. Bank street address City State Zip code <br /> 1-7�6) ` t S�- <br /> St oce td MN S5-113 <br /> All Temporary and Permanent Off-site Storage Spaces <br /> (for gambling equipment and records related to this site-must be stored in Minnesota) <br /> 13. Address (Do not use a P.O. box number) City State Zip code <br /> MN <br /> Pu t3 ce- S7 F CTj kcftli La,,&A MN 5 S- <br /> Reset Form <br />