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MINNESOTA LAWFUL GAMBLING 7/12 Page 1 of 2 <br /> LG214 Premises Permit Application Annual Fee $150 <br /> Required Attachments to LG214 <br /> 1. If the premises is leased, attach a copy of your lease. Mail the application and required attachments to: <br /> Use LG215 Lease for Lawful Gambling Activity. Gambling Control Board <br /> 2. $150 annual premises permit fee, for each permit. 1711 West County Road B, Suite 300 South <br /> Make check payable to "State of Minnesota." Roseville, MN 55113 <br /> Questions? Call 651-639-4000 and ask for Licensing, <br /> Organization Information <br /> 1. Organization name SPX)I.ILt LA Y-& AkJC- L-16Nr5 License number 4>4>S$'C <br /> 2. Chief executive officer (CEO) PF I Daytime phone _710-794'9t'-7 q <br /> 3. Gambling manager 6j!j Wt4 bDhl U/, Daytime phone 7&3-:1 4 g <br /> Gambling Premises Information <br /> 4. Current name of site where gambling will be conducted kB 1...Se-WS 914 T1 W -rAV 1Zi4 <br /> 5. List any previous names for this location <br /> 6. Street address where premises is located 4"iya 4�1l�NLCII�Y <br /> Do not use a P.O. box number or mailing address. <br /> 7. City OR Township County Zip code <br /> � 55'1 <br /> 8. Does your organization own the building where the gambling will be conducted? <br /> _Yes _X_No If no, attach LG215 Lease for Lawful Gambling Activity. <br /> A lease is not required if only a raffle will be conducted. <br /> 9. Is any other organization conducting gambling at this site? X Yes No — Don't know <br /> 10. Has your organization previously conducted gambling at this site? —Yes -)( No — Don't know <br /> Gambling Bank Account Information. Must be in Minnesota. <br /> 11. Bank name Bank account number <br /> W BLS <br /> <br /> 94%5; LAc u..Y LAgjF P M N 2.. <br /> All Temporary and Permanent Off-site Storage Spaces <br /> 13. Address (Do not use a P.O. box number) City State Zip code <br /> MN <br /> 14. tAddddress (Do not use a P.O. box number) City State Zip code <br /> MN <br />