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<br />State of Minncsota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br />Amt.Pd <br /> <br />Check # <br /> <br />e LG214PPR Prin1ed: 1218/1999 <br />License Number:A-00489-006 <br /> <br />Da1e <br /> <br />Effective Date: 5/111998 <br /> <br />Expiration Date: 413012000 <br /> <br />Name of Organization: Church of St Mary Romanian Orthodox St Paul <br />Gamblina 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: Ow- recpIds show the premises <br />is located within the city limits <br /> <br />Lessor Information <br /> <br />Goldie Katherine Siedow <br />3873 114th LN NE <br />Blaine, MN 55449 <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 />9,404.00 <br />300.00 <br /> <br />. <br /> <br />Binao Activity <br />Ow- recoIds indicate that Bingo is~conduc1ed on these premises. <br /> <br />Storaae Information <br /> <br />Bank Information <br /> <br />Firstar Bank <br />2100 N Snelling Ave <br />Roseville, MN 55113 <br /> <br />Gambling Bank <br />Account Number: 372000306 <br /> <br />On the lines provided below list the name, address and title of at least two persons authorized to sign checks and make deposits <br />and withdrawals for the gambling aCC01D1t. The organization's treasurer may not handle gambling funds. <br /> <br /> <br />Name <br /> <br />Address <br /> <br />City, State, Zip Code <br /> <br />Title <br /> <br />6> <br /> <br /> <br />S"'::>( <br /> <br />(. <br />Cf.21 <br /> <br />Cr:..:> <br /> <br /> <br />it <br /> <br />s-rll::r ~(,r <br /> <br /> <br />(Be sure to comple1e the reverse side oftltis application) <br /> <br />This form will be made available in alternative format (ie. large print, braille) upon request. <br /> <br />Page 1 of 2 (Continued on Back) <br />