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<br />fA\\~, " <br /> <br />\('2- <br /> <br />L.R <br /> <br />STATE OF MINNESOTA <br />GAMBLING CONTROL BOARD <br />PREMISES PERMIT RENEWAL APPLICATION <br /> <br />IpOR BOARD <br />IAMT PAID <br />I CHECK NO. <br />I DATE <br /> <br />USE <br /> <br />ONLY I <br />I <br />I <br />I <br /> <br />Bast <br /> <br />PRINTED: <br /> <br />LICENSE NUMBER: A-04711-001 <br /> <br />EFFECTIVE DATE: 10/01/97 <br /> <br />EXPIRATION DATE: 09/30/99 <br /> <br />NAME OF ORGANIZATION: Eartbstar projsct <br /> <br />GAMBLING PREMISES INFORMATION <br /> <br />NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br />Pot 0 Gold <br />3776 Connslly Ave <br />Arden Hills 55112 <br /> <br />COUNTY Ramsey IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br /> <br />LESSOR INPORMATION <br /> <br />DOES YOUR ORGANIZATION OWN THIS SITE?: No <br />IF NO, LIST THE LESSOR: <br />Pot 0 Gold <br />3776 Connelly <br />Arden Hills MN 55112 <br /> <br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR) : <br />Goldis Siedow <br /> <br />~ FEET PER MONTH: <br />~ FEET PER OCCASION: <br /> <br />o <br />9404 <br /> <br />AMOUNT PAID FOR RENT PER MONTH: 0 <br />AMOUNT PAID PER OCCASION: 300 <br /> <br />BINGO ACTIVITY <br />BINGO IS CONDUCTED ON THIS PREMISES: Yes IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT <br /> <br />STORAGE ADDRESS <br /> <br />3776 Connelly Ave <br />Ardsn Hills MN 55112 <br /> <br />BANK INFORMATION <br /> <br />pirstar Bank <br />4061 N Lexington Ave <br />Arden Hills MN 55126 <br /> <br />GAMBLING BANK ACCOUNT NUMBER: 812304659 <br /> <br />ON THE LINES PROVIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST TWO PERSONS <br />AUTHORIZED TO SIGN CHECKS AND MAKE DEPOSITS AND WITHDRAWALS FOR THE GAMBLING ACCOUNT. <br />THE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS. <br /> <br />Alta Bordeux - 1918 Upper Afton Rd, St. Paul, MN 55119 - President <br /> <br />Zalona VanWert - 1075 W. Shryer Ave., Roseville, MN 55113 - Director <br /> <br /> <br />Perry R. Bolin - 1954 Iglehart Ave. #2, St. Paul, MN 55104 - Gambling Mgr. <br /> <br />" <br /> <br />(BE SURB TO COMPLETE THE RBVBRSE SIDB OF THIS APPLICATION) <br /> <br />THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST <br />