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<br />--- ---------------------- <br /> <br />1--...... ..-......- -..------..... ---.-... .......~-_._--_.__. <br /> <br />Organization information <br /> <br />OrganiZatlor. namE',t/c~ 8~c ..>eJ?./e <:.4"'> <br /> <br />Name of chief executive officer (CEO) <br />l~~.s 5e:-/~~.I~..s-~ <br /> <br />8/05 <br />Page 1 of2 <br />FOR BOARD USE O~Y 'I <br />Check # $ . <br /> <br />l~' (<;pc.'~' <br />Organization license number <br />..>1'" n ~. Z Z'J'- <br />Daytime contact phone number <br />bSI -'-1. -(.",'-('- <br />Not the mailing address. <br />Gambling premises information ~~~2 P.O~box ~~..:... _.J . <br />Name of establishment where gambling will be conducted Street address where premises Is Jocated <br />..f' 4:- -e,J 13<<V" -,1/ - ~.r...t/ 70 f8 Ce~~"'f//~ ".:k' <br />City Township County Zip code <br /> <br />cete/e""'v~/Ic;., OR.I ff4eP ~ ~ ..rs-038 <br />Does your Qrganization own the building where the gambling wm be conducted? <br />_Yes ~o If no, attach LG215 Lease for Lawful Gambling Aj:IMty <br /> <br />.~ <br /> <br />Minnesota Lawful Gambling <br />LG214 Premises Permit Application <br />(see Required Attachments on Page 2) Annual Fee $150 <br /> <br /> <br />Gambling bank account information <br />Bank name <br /> <br />Bank account number <br /> <br />~c~5h-esl- B~~ 30 //t3z..- <br />Bank street address CIty State/Zip code <br />1(;..70.5 ".,.twe:. 6 ~ . ~"'~d r- ~ H .r..:iDZ~ <br />Address(es) In Minnesota of all temporaryand permanent off-sltestoragespace for gambling <br />equipment and records related to this site (may not be stored outside of Minnesota) <br />Address (Do not use a P.O. box number) CIly state/Zip code <br />-t /7b-4' .$~"V ~ H,V S.$l/3B <br /> <br />Bingo occasions (including bar bingo) <br />Enter day and beginning/ending hourS of bingo occasions (Indicate A.M. or P.M.). An occasion may not exooed 8 hours. <br />~ Be9innina/Endina Hours ~ Beglnnlna/Endlng Hours <br /> <br />". to to <br />~-Iv"...R~T Z/>~ to ~A~ to <br />, , <br /> to to <br /> to to <br /> to to <br /> .- <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> <br />3~ <br /> <br />1,- <br />