Laserfiche WebLink
Premises Permit Application - LG214 Page 2 of 3 <br /> 1/99 <br /> Bingo Occasions - for Class A or C Permits <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 /> Day Reginning/Ending Hours Day fleoinning /Fnding Hours pay Beginning /Ending Hours <br /> to to _ to <br /> to __ to to <br /> to to to <br /> to <br /> Gambling Bank Account Information <br /> Bank name Bank account number* <br /> /l R \ - I47 . P$'r es-ann. /C? 7 or 3'/ <br /> Bank address City State /Zip code <br /> • New organizations: The account number may be odtained an. submitted to the Gambling Control Board within <br /> ten days after you receive your premises permit. <br /> C •t`.� 't ,, .: �e<, ,":� w�u °sys sni - �•r ,��`,�^,�+; s,l*r�, a"�'7 �` � A� "�- `� i <br /> i n `s'.*'.�r r 3aa�.`,� <br /> :tdfl%.w <br /> Name Address Title <br /> I .'t�' 1 tip, V'L26 <br /> IC v L A r s o a ? 3 ere . b. r- J7v ? s/3 ' 2 / ( � eta s ! ; cf tz -�' <br /> l�F GIvI ICE' ( .I eY ` 4..3 tie v Pr S N3 Z <br /> ♦�K sS ere I. I t YC. 11.10 v, cc gF';. <br /> n'r,tiu 11 7tt-t"0.i s 7 4 1d? (rtttri• r/r (pid(C “7/37455"isrL-1wLir„ 4 ►amgfi, <br /> Acknowledgment Oath <br /> I declare that: <br /> Gambling site authorization 1. I have read this application and all information submitted <br /> I hereby consent that local law enforcement officers, the to the board is true, accurate, and complete; <br /> board or agents of the board, or the commissioner of <br /> revenue or public safety or agents of the commissioners, 2. all other required information has been fully disclosed; <br /> may enter the premises to enforce the law. 3. I am the chief executive officer of the organization; <br /> Bank records information 4. I assume full responsibility for the fair and lawful <br /> The board is authorized to inspect the bank records of the operation of all activities to be conducted; <br /> gambling account whenever necessary to fulfill 5. I will familiarize myself with the laws of Minnesota <br /> requirements of current gambling rules and law. governing lawful gambling and rules of the board and <br /> agree, if licensed, to abide by those laws and rules, <br /> Organization license authorization including amendments to them; <br /> I hereby authorize the Gambling Control Board to modify 6. any changes in application information will be submitted <br /> the class of organization license to be consistent with the to the board and local unit of govemment within ten <br /> class of permit being applied for. days of the change; and <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 /> � � a / 0 c e'DO <br /> Signature of chief ex u ti a officer (Designee may not sign) Date <br />