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CLIM~ ~EATRE <br /> <br />PAGE <br /> <br />Minnesota Lawful Gambling [ FOR BOARD USE ONLY <br />LG214 Premises PermitApplication /Check# Amount <br /> <br /> Expimtation date <br /> <br />C~ass of Permit Premises Perm'it''Fee <br /> -' During 2nd year of ' ' <br />Check one Two years., organ, iza_.tion, license <br />F-Z] Cl.s~ A- Pull-mb~. tipboard,, paddlewheels, raffles, bingo $40Q., ( <br />[] Class B- Pull4abs, t[pboards, paddlewheels, raffles $250 <br />[] Class C - Bingo onlyOR bingo and pull-tabs when total gross $2.00 $100 <br />receipts does not exceed $50,000 per year <br />[] Class D - Ra~es only $150 $ 75 <br /> <br />J! <br /> <br />! <br />I <br /> I <br /> I <br /> I <br /> <br />Organization Information <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Internal Revenue Service) <br /> <br />Name of chief executive officer (cannof be your gambling manager) <br /> <br />Organization licensenumber <br /> <br />Daytime phone number, <br />including area code <br /> <br />I <br />I <br />I <br /> <br />j Gambting Premises Information <br />JName of establishmenf~where gambling will be conducted Street add tess (do net use a P.O, box number) <br /> <br />~~ w~e~ ga&bling p~m(~ ~Z~wnshlp & ~un~he~ g~m~ng p~m~ is ~'~ ~ ~m~_ <br /> <br /> Is [he pre~i¢~s [oca{e~ within cl[ylimits? Yes ~ No ~ If No, b ~ownship: ~ Organ~ed <br /> ~ Uno~en}~ <br /> ~ Uninco~rat~ <br /> <br />Does your organization own bhe building where the gambling wdll be conducted? <br />r-~Yes []No If no, attach(I) the appropriate lawful gambling lease form, and <br /> (2) the sketch of all leased areas with dimensions and square footage clearly defined <br /> A lease and sketch are not required for class D applications. <br /> <br />Name of legal owner of premises Address City State/Zip <br /> <br />Address(es) of Storage Space of Gambling Equipment <br />Ust all locations where used ;and unused gambling product ~ Bt~md. Do not use a P.O. box number. <br />(Attach an additional sheet if necessary.) <br /> Address City State/Zip <br /> <br />-120- <br /> <br /> <br />