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<br />Minnesota Lawful Gambling <br />LG214 Premises Permit Application <br /> <br /> <br />Annual Fee $150 6/07 Page 1 of2 <br /> <br />FOR BOARD USE ONLY <br />. Check # <br />$ <br /> <br />Licensenumber 0'-\ ;;1.4\ <br /> <br />Organization name ~ d \ ~o'-\,-..d 1>.\\0"'-' <br /> <br />Chief executive officer (CEO) <br /> <br /> <br />Daytime phone b S' - (:;~;1-? bE:.S <br /> <br />Name of establishment where gambling will be conducted f=" I \;\~'Q;Q_~.s. C\qQ~", 1t,C:>'-l)\ <br /> <br />Street address where premises is located 1';l"T3. \..U. <::"0. ~d.. ~ <br />(Do not use a P.O. box number or mailing address) <br /> <br />City Township County Zip code <br /> <br />I_~~~~~--~~~~---~~---------------------------------~~~~~~______________~~_~~~_____ <br /> <br />Does your organization own the building where the gambling wi.!1 be conducted? <br /> <br />Yes XNo If no, attach LG215 Lease for Lawful Gambling Activity <br /> <br /> <br /> <br />Bank name <br /> <br />Bank account number <br /> <br />~~~~~~~__~~_~~~~_________________L~~~~~~___________________________ <br />Bank street address City <br />I'S()\ \..A.). ~D. '<.cl ~ ~';olW\\\Q <br />All Temporary a fbff-$HeSt <br />(for gambling equipmeri't'an I.ated t&this site?: <br />Address (Do not use a P.O. box number) <br />__R~L__?~ '5~tS-+ ,W <br /> <br />Bin~o Occasions ([hi::lJ.ll:lin.!fbarbingo) <br /> <br /> <br />Enter day and beginning/ending hours of bingo occasions (indicate A.M. or P.M.). An occasion may not exceed 8 hours. <br /> <br />1m <br />-~~Q~- <br />-[.Q-~---- <br />::rh_L,l-f~__ <br /> <br />Beainnina/Endina Hours <br />_____f,d, 3D _ to _'1.L~_CZ___ <br />____~L~Q_ to __-q; 3Q__ <br />_____~ '3_~ to 3-,~-Q--- <br /> <br />1m <br /> <br />Beainnina/Endina Hours <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br />to <br /> <br /> <br />to <br /> <br />to <br /> <br />OA' I ... <br />no-+- 'S(A..{"~ w~ D+h'tf n"fj h-r () vJl:-. POSS, bI;1 <br />()J&J. or- ThU'\s" f'I\'l:Q...k (,C1.~\tS ch.d\r?1 l))'?,) )'lOT <br />Su.Cf D+- c\. "~'r"" Ij~t.. <br />