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<br />State of Minnesota <br />Gamb6ng Control Board <br />Premises Permit Renewal App6cation <br /> <br />For Board Use Only <br />Amt. Pd <br /> <br />Check # <br /> <br />LG214PPR Printed: 1/1 0/2003 <br /> <br />License Number:B-00584-010 Effective Date: 8/1/2001 Expiration Date: 7/31/2003 <br />Name of Organization: Spring Lake Park Lions Club <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br /> <br />Kellys Korner <br />7098 Centerville Rd <br />Centerville, MN 55038 <br />. County: Anoka <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: 7 ~ <br />Rent paid per month: * /(:)0 () . 00 <br />Square footage leased per bingo occasi9n: #.a II t <br />Rent paid per bingo occasion: }J, i1 . <br /> <br />Dinlo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />Storale Information <br /> <br />8433 Center Dr <br />Spring Lake Park, MN 55432 <br /> <br />Bank Information <br /> <br />Wells Fargo Bank <br />8455 NE Plaza Blvd <br />Spring Lake Park, MN 55434 <br /> <br />Gambling Bank <br />Account Number: 1080034913 <br /> <br />On the lines provided below list the name, address and title of at least two persoDS 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 Address City, State, Zip Code <br /> <br />Dean Harold Keller 528 79th Ave.NE Spring Lake Park, MN <br />55432 <br />Spring Lake Park, MN <br />55432 <br />Spring Lake Park, MN <br /> <br />Title <br /> <br /> <br />8433 Center Dr <br /> <br /> <br />lle -r':1 e- <br /> <br />- $/ 11 ~ <br /> <br />(Be sure to complete the reverse side of this application) <br />This form will be made available in alternative format (ie. large print, braille) upon request. Page 1 of 2 (Continued on Back) <br /> <br />8433 Center Dr <br />