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<br />Sta te of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br /> <br />A-\ <br /> <br />Amt. Pd <br /> <br />Check # <br /> <br />.LG214PPR Prin1ed: 9/5/2001 <br /> <br />License NumberA-04241-001 <br /> <br />Effective Date: 4/1/2000 <br /> <br />Expiration Date: 3/31/2002 <br /> <br />Name of Organization: 621 Shoreview Found <br />Gamblin!: Premises Information <br /> <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 located within the city limits <br /> <br />4 rde~ \-10115 <br /> <br />Lessor Information <br /> <br />Name of the property owner (If different): <br />G-o/<l1 ~fQW <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: --300. <br /> <br />g, (",4$ <br />4<j zt. <br /> <br />. <br /> <br />Bin!:o Activity <br />Our records indicate that Bingo is conducted on these premises. ptease refer to the instructions for required <br /> <br />Stora!:e Information <br /> <br />251 NW 5th St E-Z Mini Se <br />New Brighton, MN 55112 <br /> <br />Bank Information <br /> <br />w",/I~ r:""'!jc <br />Nttrwest BAnI.. MIDDesola NA <br />1220 W CoRd E <br />Arden Hills, MN 55112 <br /> <br />Gambling Bank <br />Account Number: 3970272510 <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 and <br />withdrawals for the gambling account. The organization's treasurer may not handle gambling fimds. <br /> <br />Name <br /> <br />Address <br /> <br />City, State, Zip Code <br />Arden Hills, MN 55112 <br /> <br />Title <br /> <br />Gerald Laurence McCauley <br /> <br />1925 Jerrold Ave <br /> <br />Sharron FitzGerald <br /> <br />3970 Evergreen Place <br /> <br />Shoreview, MN 55126 <br /> <br />Ga..-bi. n . ()'k.......("fOi?.,..., <br />?~,t c: EO. <br /> <br /> <br />(\l",cc:,c:. Che~e <br /> <br />/I '1<: 0 1C....rf h '-de", ik <br /> <br />Acde~ /-1,115, (Y)~.5S '12. <br /> <br />CEo <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This form will be made available in alternative fonnat (ie. large print, braille) upon request. <br /> <br />Page 1 of 2 (Continued on Back) <br />