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<br />FOR BOARD USE ONLY <br />Check # <br />Initials <br />Date <br /> <br />Minnesota Lawful Gambling <br />Premises Permit Application - LG214 <br /> <br />Base # <br />PP# <br /> <br />Fee <br /> <br />Class of Permit <br />Check one: <br />o Class A - $400 Pull-tabs, tipboards, paddlewheels, raffles, bingo <br />18.1 Class B - $250 Pull-tabs, tipboards, paddlewheels, raffles <br />o Class C - $200 Bingo only OR bingo and pull-tabs when total gross receipts do not exceed $50,000 per year <br />o CI~ss D - $150 Raffles only <br /> <br />Page 1 of 3 <br />1/99 <br /> <br />Organization Information <br /> <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Internal Revenue Service) <br /> <br />Base license number <br /> <br /> <br /> <br /> <br />Daytime phone number <br />( ~ J 2.) 124 elJ '1 cl <br /> <br />Na e of ch' f executive officer (cannot be your gambling manager) <br /> <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted <br /> <br />Street address (do not use a P.O. box number) <br /> <br /> <br />NoD <br /> <br />If No, is township: ~ Organized <br />o Unorganized <br />o Unincorporated <br /> <br />Does your organization own the building where the gambling will be conducted? <br />DYes I23-No If no, attach (1) the appropriate lawful gambling lease form, and <br />(2) the sketch of all leased areas with dimensions and square footage clearly defined <br />A lease and sketch are not required for class D applications. <br /> <br />Name of legal owner of premises Address City State/Zip <br /> <br /> <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not use.a P.O. box number. (Attach an additional <br />sheet if necessary.) <br />Address StatelZip <br /> <br /> <br />A1tJ <br /> <br />5 (.'J 38' <br /> <br />Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. If you use a TrY, you can <br />call the Board by using the Minnesota Relay Service at 1-800-627-3529 and ask to place a call to 651-639-4000. This <br />form will be made available in alternative format (i.e. large print, Braille) upon request. <br />