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<br />Premises Permit Application - LG214 <br /> <br />Page 2 of 3 <br />1/99 <br /> <br />Bingo Occasions - for Class A or C Permits <br /> <br />If applying for a class A or C permit, enter days and beginning/ending hours of bingo occasions (indicate A.M. or P.M.). No <br />more than ten bingo occasions may be conducted per week. An occasion must be at least one and one-half hours, not to <br />exceed four hours. <br /> <br />QQy Beginning/Ending Hours QQy Beginning/Endina Hours Qgy Beginning/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 /> <br />Gambling Bank Account Information <br />Bank name <br />! <br /> <br /> <br />Y')Lc~ I iv <br />* New organizations: The account number may be 0 <br />ten days after you receive your premises permit. <br /> <br />to <br /> <br />to <br /> <br />Bank account number* <br /> <br /> <br />Acknowledgment <br /> <br />Gambling site authorization <br />I hereby consent that loca/law enforcement officers, the <br />board or agents of the board, or the commissioner of <br />revenue or public safety or agents of the commissioners, <br />may enter the premises to enforce the law. <br /> <br />Bank records information <br />The board is authorized to inspect the bank records of the <br />gambling account whenever necessary to fulfill <br />requirements of current gambling rules and law. <br /> <br />Organization license authorization <br />I hereby authorize the Gambling Control Board to modify <br />the class of organization license to be consistent with the <br />ciass of permit being applied for. <br /> <br />~cI'd~~.k~ <br />::;i~nature of chief exe utive officer (Designee may not sign) <br /> <br />Oath <br />I declare that: <br />1. I have read this application and all information submitted <br />to the board is true, accurate, and complete; <br /> <br />2. all other required information has been fully disclosed; <br /> <br />3. I am the chief executive officer of the organization; <br /> <br />4. I assume full responsibility for the fair and lawful <br />operation of all activities to be conducted; <br /> <br />5. I will familiarize myself with the laws of Minnesota <br />governing lawful gambling and rules of the board and <br />agree, if licensed, to abide by those laws and rules, <br />including amendments to them; <br /> <br />6. any changes in application information will be submitted <br />to the board and local unit of government within ten <br />days of the change; and <br /> <br />7. I understand that failure to provide required information <br />or providing false or misleading information may result <br />in the denial or revocation of the license. <br /> <br />~/;;10 I :;;CJ::JO <br />Date <br />