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<br /> I ..- l ik:_ <br /> t~4,r..- <br /> - 1;;/ } 1~ <br /> It STATE OF MINNESOTA IFOR BOARD USE ONLY I <br /> GAMBLING CONTROL BOARD IAMT PAID_'_____I <br /> PREMISES PERMIT RENEWAL APPLICATION I CHECK NO, I <br /> R PRINTED: JDATE I <br /> NUMBER: A-047l1-00l EFFECTIVE DATE: 10/01/fd'17 EXPIRATION DATE: 09/30/<;q 7'1 <br /> irE OF ORGANIZATION: Earthstar Project <br /> ~--~ <br /> GAMBLING PREMISES INFORMATION <br /> IlE OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br /> ~ 0 Gold <br /> 776 Connelly Ave <br /> len Hills 55112 <br /> OUNTY Rams ey IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br /> I LESSOR INFORMATION <br /> OES YOUR ORGANIZATION OWN THIS SITE?: No <br /> IlNO' LIST THE LESSOR: <br /> o Gold <br /> 6 Connelly <br /> .rden Hills MN 55112 <br /> IlE OF PROPERTY OWNER (WHEN NOT LESSOR) : <br /> oldie Siedow <br /> ~ FEET PER MONTH: 0 AMOUNT PAID FOR RENT PER MONTH: 0 <br /> Q FEET PER OCCASION: 7990 AMOUNT PAID PER OCCASION: 300 <br /> It BINGO ACTIVITY <br /> GO IS CONDUCTED ON THIS PREMISES: Yes IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT <br /> 16 Connelly Ave STORAGE ADDRESS <br /> rden Hills MN 55112 <br /> I BANK INFORMATION , <br /> 'J.rstar Bank <br /> Irl N Lexington Ave <br /> en Hills MN 55126 <br /> :AMBLING BANK ACCOUNT NUMBER: 812304659 <br /> liTHE LINES PROVIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST TWO PERSONS <br /> ,UTHORIZED TO SIGN CHECKS AND MAKE DEPOSITS AND WITHDRAWALS FOR THE GAMBLING ACCOUNT. <br /> Ir ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS, <br /> Sheila WhiteEagle <br /> I Perry R~ Bolin <br /> ,. Jerrv Cobenais <br /> (BE SURE TO COMPLETE THE REVERSE SIDE OF THIS APPLICATION) <br /> lIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST <br />