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<br />, <br /> <br />~ <br /> <br />State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br />Amt Pd <br /> <br />Cheek # <br /> <br />LG214PPR Printed: 3/112002 <br /> <br />License Number:B-03800-008 <br /> <br />Effective Date: 10/112000 <br /> <br />Expiration Date: 9/3012002 <br /> <br />Name of Organization: Dead Broke Saddle Club <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br /> <br />Trio Inn <br />7082 Centerville Rd <br />Centerville, MN 55038 <br />County: Anoka <br /> <br />Note: Our records show the premises <br />is located within the city limits <br /> <br />Lessor Information <br /> <br />Name of the property owner (If different): <br /> <br />flre,-./ /1011.-I-e'",-- <br />(; S-/o C CAhrUil/", ,fcC? <br /> <br />Square footage leased per month: '/C) <br />Rent paid per month: f'a::; <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: rzr <br /> <br />Binl!;o Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />ef <br /> <br />J /"20 ) ~" ,,- <br /> <br />#;/ .>>038 <br /> <br />II~Yo""ctJ <br />19680 I1erroH Ave <br />Forest Lake, MN 55025 <br /> <br />Storal!;e Information <br /> <br />:n: 7C <br /> <br />/7& r7 5,L- <br /> <br />/1 <br />//"';)0 <br /> <br />H,v ~5-0 3& <br /> <br />/l",-,,<- 5r'",,-~ r g~e"'?<:'- <br />Tile C8unt). BAllI,. <br />1650 South Lake St <br />Forest Lake, MN 55025 <br /> <br />Bank Information <br /> <br />Gambling Bank <br />Account Nwnber: 3011821 <br /> <br />On the lines provided below list the name, address and title of at least two persons authorized to sign checks and make deposits and <br />withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br /> <br />Michael Burress 9243 N 55th 5t Lake Elmo, MN 55042 C ~ c:;; <br />Tom Schafib:Usen 10010 240th 5t N 5candia,MN 55073 13o~/.e M e-...k.,. <br />ave .Clettfrton 8U8 181st Ave N Forest Lake, MN 55025 !/A:.?C h<"5 <br />t:. A:~#,,"~ r-c----- <br /> <br />Name <br /> <br />Address <br /> <br />City, State, Zip Code <br /> <br />Title <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This form will be made available in alternative format (ie. large print, braille) upon request. <br /> <br />Page 1 of2 (Continued on Back) <br />