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<br />Minnesota Lawful Gambling <br />LG214 Premises Permit Application <br />(see Required Attachments on Page 2) Annual Fee $150 <br /> <br />.~ <br /> <br />8/05 <br />Page 1 of2 <br />FOR BOARD USE ON~yl <br />Check # $ . <br /> <br />f,' (}JPC}'~> <br />Organization license number <br />t;..>/~ Yt-t/. 7Z ZJ''- <br />Daytime contact phone number <br />b 5 I - (-<.,.c-(1' - <br /> <br /> <br />l----'.-.-~-.- -_...~,._._--_.~,.-- ---------~---... <br /> <br />. Organization information <br /> <br />OrganiZation name /) r7 - /' <br />/./z'~ 8,n;;;{ It: ..5..eej?/c e:.4'~,J <br />Name of chief executive officer (CEO) <br />l~~~.s .$G--ff!:.~,t~.s-~ <br /> <br />Not the maiDng address. <br />Gambling premises information D2.not~~ P.O..:-box ~mbe!.:... _.J <br />Name of establishment where gambling wlll be conducted Street address where premIses Is located <br />5 ~ -e"" J /.34V' -;1/ - tr.r...1/ 7" ft3 c e;t.';;:'~f./I/k /J,R' <br />CIty Township County Zip code <br /> <br />ce~""vrll~ OR.I ffifet>~r.- ~..ro.38 <br />DoeS your Qrganization own the building where the gambling will be conducted? <br />_Yes XNo If no, attach LG215 Lease for Lawful Gambling Ac::t:ivIty <br /> <br />Gambling bank account information <br />Bank name <br /> <br />Bank account number <br /> <br />~,C""l.--5h-.e.,i- B~,,- ~~ / / r3z, <br />Bank street address City State/Zip code <br />1'-.70..5 ~.".(~ !5 r -v"'ed r- ~ k .5'.f't::JZ~ <br />Address( es) in Minnesota of all temporary and permanent off-site storage space 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) CIty State/Zip code <br />-t /7t:74' $r- g ~. HP S-,503B <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 exceed 8 hours. <br />~ J3eginnina/Endina Hours ~ J3eginnlna/Endlng Hours <br /> <br />... to to <br />~-li/rt!leT. Z /> WI.- to ~A~ to <br />, II' . . <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 />