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FOR BOARD USE ONLY <br /> !,G21 BASE # — <br /> PP #_ <br /> FEE <br /> Minnesota Lawftd Gambling CHECK <br /> INI <br /> Premises Permit Application - Part 1 of 2 DATE TIALS <br /> P-P 1 .-MR <br /> Class of premises permit <br /> Renewal (check one) <br /> Organization base license number A ($400) Pull-tabs, tipboards, paddlewheels, raffles, bingo <br /> Premises permit number B ($250) Pull-tabs, tipboards, paddlewheels, raffles <br /> New ❑ C ($200) Bingo only <br /> D($150) Raffles only <br /> or Ir <br /> janiz -atib "._ 1 ' It , r <br /> Name of Organization <br /> Easiness Address of Organization - Street or P O Box (Do not use the address of your gam bling manager) <br /> "t stale Zip Code Coun ty Daytime phone number <br /> 77ZJ <br /> Name of chief executive officer (otinnot be your gambling manager) Tide I Daytime phone ncmber <br /> Bingo Occasions <br /> If applying for a class A or C permit, fill in days and beginning & ending hours of bingo occasions: <br /> No more than seven bingo occasions maybe conducted by your Organizatio per week. <br /> Cay Beg! nning/Endirig Hci= Day Beonning./Endi-ng Hours Day Beginnhng /Ending Hours <br /> to to — to <br /> t to — to <br /> to if bingo will not be conducted, check here <br /> Gambling Premises „Information <br /> Name of es irri post ottsciii,lbox nucpber) <br /> l ar h <br /> I s the premises located within city limits? =Yes MNo It no, is township ry qanlzed unorganized � unincorporated <br /> Cry and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br /> It— <br /> Name and address of legal owner of premises City State Zip Code <br /> j <br /> Cces your organization own the building where the gambling will be conducted? =YES NO <br /> It no, attach the following: <br /> • a copy of the lease (form LG202) with terms for at least we year. <br /> a copy of a sketch of the Roar plan with dimensions, showing what portion is being leased. <br /> A lease and sketch are not required for Class 0 applications. <br /> Address of si6 a s pace of gi "Iln � . il rne Do not tine a <br /> Address City State Zip code <br />