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<br />~ast STATE OF MINNESOTA I FOR BOARD USE ONLY I
<br />GAMBLING CONTROL BOARD I ANT PAID I
<br />~ " ,.. . PREMISES PERMIT RENEWAL APPLICATION I CHECK NO, I
<br />~ PR PRINTED:. . . I DATE I
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<br />,ICENSE NUMBER: A-04241-001 EFFECTIVE DATE: 04/01/96 EXPIRATION DATE: 03/31/98
<br />rAME OF ORGANIZATION: 621 Shoreview Found
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<br />GAMBLING PREMISES INFORMATION
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<br />rAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED
<br />?ot 0 Gold Bingo
<br />l776 Connelly Ave
<br />,rden Hills 55112
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<br />:OUNTY Ramsey IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y
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<br />LESSOR INFORMATION
<br />)OES YOUR ORGANIZATION OWN THIS SITE?: No
<br />:F NO, LIST THE LESSOR:
<br />?ot 0 Gold
<br />)776 Connelly
<br />\rden Hills MN 55112'
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<br />rAME OF PROPERTY OWNER (WHEN NOT LESSOR) :
<br />}oldie Siedow
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<br />'. FEET PER MONTH: 0 AMOUNT PAID FOR RENT PER MONTH: 0
<br />3 FEET PER OCCASION: 9404 AMOUNT PAID"PER OCCASION;' 300
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<br />BINGO ACTIVITY ..<..,.c.....,., .',:"."'.,,',"',c ."""'. ..;."
<br />lINGO IS CONDUCTED ON THIS PREMISES: Yes IF-YES, REFER TOINSTR'ti'CTIONS"FOR:REQUIRED'ATTACHMENr
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<br />l51 NW 5th St E-Z .Mini' Se " .. ,.,.., .,., . . ',."'.: ". ,,'.
<br />Iew Brighton- -~ 55112"'- ~ ,~~ -'.' .,.~;,.' "Y<,.. '~.~~:~_~o;.~~~J;':;:~;::~-'/ >:~j~;- ;;:~~.,f:r;;~~<:':~~:,,~A:: .'. .~~:;>?~:~~:::~~
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<br />~AMBLING BANK ACCOUNT NUMBER:' 3970272510.. "",..-".:,.>", :'.":';: .,. ',," ..,"
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<br />IN THE LINES PROVIDED BELOW LIST THE'NAME, ADDRESS AND TITLE..OF:AT LEASTTWO..PERSONS.
<br />WTHORIZED TO SIGN CHECKS AND MAKE DEPOSITS AND' WITHDRAWALS"FORTHE'GAMBLING ';ACCOUNT;'
<br />., . . . . '. .... _ ~ ,__ ,. - '_"'_'" ..",'- " ,-r,'.' ".-.-- . '.- ,'.' '.<<. -- ..-~ .. .:'
<br />rHE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS. :.J:i::' , .,'.:..,: ,,>;0,' ,.
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<br />THIS' FORM WILL'BE : MADE AVAILABLE "INALTERNATIW': FORM:AT>(I : E ,"':;iARGEfPRINT ;:BRAILLE) ';..tiPoN ;lriiQUEST .
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