2002-03-13 CC Packet - Laserfiche WebLink

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LG214 - Premises Permit Application Bingo Occasions for Class A or C Permits If applying for a class A or C permit, enter day and beginning/ending hours of bingo occasions (indicate A.M. or P.M.). No more than ten bingo occasions may be conducted per week. An occasion must be at least one and ane-hatf hours, not to exceed four hours. Dav Beainnina/Endina Hours Dav to to to to Noon Hour Bingo Only ~ Beainnina/Endina Hours Dav Beainnina/Endina Hours to to to to Gambling Bank Account Information Bank name << -'.. S'/,' . .....,~. /3", '"' 4-..- Bank street address c/ c .5-r- Page 2 of 3 7/01 Beainnina/Endina Hours Dav Beainnina/EncLina l::Iours " to to to to to to Dav Beainnina/Endina Hours to to to Bank account number' City ;/"f/'-:J /- . New organizations: The account number may be obtained and submitted to the Gambiing Controi Board within ten days after you receive your premises permit. Name, address, and title of members authorized to sign checks from the gambling account. The organization's treasurer may not handle gambling funds. Name Street Address City Zip Code ,'"" . \~ \4:l'OO \.\ CtI.'(""<""OlA..) ~'-V" ~o re~"\"'" L.c.,v mY'- S5oz..S . '-\- t-l>.. So+- V' Acknowledgment Gambling site authorization I hereby consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or public safety or agents of the commissioners may enter the premises to enforce the law. Bank records information The board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. Organization license authorization I hereby authorize the Gambling Control Board to modify the class of organization license to be consistent with the class of premises permit being applied for. Oath [ declare that: I. I have read this application and all information submitted to the board is true, accurate, and complete; 2. all other required information has been fully disclosed; 3. I am the chief executive officer of the organization; 4. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 5. [will familiarize myself with the laws of Minnesota governing lawful gambling and rules ofthe board and agree, if licensed, to abide by those laws and rules, including amendments to them; 6. any changes in application information will be submitted to the board and local unit of government within ten days of the change; and 7. I understand that failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. S -c;.-o ;L- Date