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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 /> UseLG215 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 5�'t' � t.. ,._ Zr–, Lj&hh License number' <br /> 2. Chief executive officer(CEO) " " .. -L – Daytime phone -7o--744-91,_ <br /> 3. Gambling manager '`_HAWt b09t!_}4L)4 Daytime phoneme <br /> Gambling Premises Information <br /> 4. Current name of site where gambling will be conducted ) -- i <br /> 5. List any previous names for this location l <br /> 6. Street address where premises is located -1Q3, 11WAY LD <br /> Do not use a P.O.box number or mailing address. <br /> 7. City Township County Zip code OR <br /> S. 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 /> A lease is not required if only a raffle will be conducted. <br /> 9. Is any other organization conducting gambling at this site? Yes — No — Don't know <br /> 10. Has your organization previously conducted gambling at this site? _Yes X._ No _ Don't know <br /> Gambling Bank Account Information. Must be in Minnesota. <br /> 11. Bank name <br /> 12. Bank street address City Sta <br /> 9455 LA N <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. Address (Da not use a P.O. box number) City State Zip code <br /> MN <br />