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<br />" <br /> <br />State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br />Amt Pel <br />Check # <br />Dale <br />Initials <br /> <br />,. <br /> <br />LG214PPR Printed: t 1115/1999 <br /> <br />License Number:A-04241-001 <br /> <br />Effective Date: 4/1/1998 <br /> <br />Expiration Date: 3/3112000 <br /> <br />Name of Organization: 621 Shoreview Found <br />Gamblin2 Premises Information <br />Name of the establishment where gambling will be conducted <br /> <br />Pot 0 Gold Bingo <br />3776 Connelly Ave <br />Arden Hills, MN 55112 <br />County: . Ramsey <br /> <br />Note: Our records show the premises <br />is localed within the city limits <br /> <br />.~."' . <br /> <br />. . " "; "LeS80dnformation <br /> <br />.4.\ <br /> <br />><~"..~\:1.': <br /> <br />, <br /> <br />. ,"' . ~ " <br /> <br />.<.... <br /> <br />Name of the property owner (If different): <br /> <br />Square footage leased per month: <br />Rent paid per month: <br />'Square footage leased per bingo occasion: . <br />Rent paid per bingo occasion: <br /> <br />Bin20 Activity <br />Our records indicate that Bingo is DOt conducted on these premises. <br /> <br />9,404." <br />300.. <br /> <br />f..z.. :st-Dr"':\G - <br />(1,\......, B ""Ijh+-D~ <br /> <br />;2. 5 J _ 5'CI-,..sr. Stora2e Information <br /> <br />'Ss 1/.. <br /> <br />Bank Information <br /> <br />Norwest Bank Minnesota NA <br />1220 W Co Rd E <br />Arden HiUs, MN 55112 <br /> <br />Gambling Bank <br />Account Number: 3970272510 <br /> <br />On 1I1e lines provided below list 1I1e name, address and title of at least two persons authorized to sign checks and make deposits and <br />wi1l1drawals fur the gambling account The organization's trellSurer may not handle gambling funds. <br /> <br />Name <br /> <br />Address <br /> <br />City, State, Zip Code <br /> <br />5h.,..cv,c:;"';, m",," <br />5~11- <br />A,...tI~n UfllsJ m",. <br />5511z... <br /> <br />Title <br />C E. O. <br />G-6-,,/.ftj <br />rt'141"" e.r <br /> <br />ShLI"ro ..... <br />Fdz. e....~G.I.t <br /> <br />G.........(cl. <br />(>'\c. (! <>.." t.:. <br /> <br />!Jq 1 0 Go V <"'j,..... p/6..G<. <br /> <br />I'PS <br />.re..~ro JJ Ave. <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This fonn will be made available in alternative format (ie. large print, braille) upon request <br /> <br />Page I of 2 (Continued on Back) <br />