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<br />State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />;, (-----'~ G-1J L..~ 1..-- E' D 'I i__ <br />For Board Use Only <br /> <br />Amt. Pd <br /> <br />Check # <br /> <br />eG214PPR Printed: 10/1612001 <br /> <br />License NumberA-004S9-006 <br /> <br />Effective Date: 5/112000 <br /> <br />Expiration Date: 4/3012002 <br /> <br />Name of Organization: Church ofSt Mary Romanian Orthodox St Paul <br />Gamblin~ 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 located within the city limits <br /> <br />Lessor Information <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 />e <br /> <br />Bin~o Activity <br />Our records indicate that Bingo is conducted on these premises. Please refer to the instructions for required <br /> <br />I <br /> <br />Stora~e Information <br /> <br />3776 Connelly Ave <br />Arden Hills, MN 55112 <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 and <br />withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br /> <br />Name <br /> <br />Address <br /> <br />City, State, Zip Code <br />S'5't IF <br />h("I~ ,,~ Jlfitl <br /> <br />Title <br /> <br />Nicholas Manciu <br /> <br />1 r II.. ""(<Dill..... <br /> <br />C-f.-o <br /> <br />,J;m Jullll E_lIoti <br /> <br />92S18tl.J..e~1 <br /> <br />$.ea.h St. P~nll, hH4 .1S97'- <br /> <br /> <br />< <br />(Be sure to complete the reverse side of this application) <br /> <br /> <br />>tIC, <br /> <br />KfrfL <br /> <br />This form will be made available in alternative format (ie. large print, braille) upon request. <br /> <br />Page 1 of2 (Continued on Back) <br />