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Page 1 of 3 <br /> 7/01 <br />Minnesota L awful Gambling I FOR BOARD USE ONLY I <br /> Check # Amount <br /> I <br />LG214 Premises Permit Application E~xpiratation date <br /> <br />Class of Permit Premises Perr~it Fee <br /> During 2nd year of <br />Check one Two years organization license <br />[] Class A - Pull-tabs, tipboards, paddlewheels, raffles, bingo SA00 $200 <br />Class 8 - Pull-tabs, tipboards, paddlewheels, raffles $250 $125 <br />[] Class C - Bingo only OR bingo and pull-tabs when total gross $200 $100 <br />receipts does not exceed $50,000 per year <br />~ Class D - Raffles only $150 $ 75 <br /> <br /> I <br /> I <br /> I <br />I <br />! <br />I <br />I <br />I <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 />Organization license number <br /> <br />Name of chief executive officer (cannot be your gambling manager) <br /> <br />Daytime phone number, <br />including area code <br /> <br />Gambling Premises Information <br />Name of establishment where g ambling will be conducted <br /> <br />Street address (do not use a P,O. box number) <br /> <br />Cib/& county where gambling premises is located-OR--Township & county where gambling premises is located if outside city lira <br /> <br />Is the premises located within city limits? Yesj~ NoG IfNo, is township: [] Organized <br /> [] Unorganized <br /> E~ Unincorporated <br /> <br />Does your or.~anization own [he building where the gambling will be conducted? <br />[] Yes .~No If no, attach (1) the appropriate lawful gambling lease form, and <br /> (2) the sketch of all leased areas with dimensions and square footage clearly deft'ned <br /> A lease and sketch are not required for class 0 applications. <br /> <br />Name of legal owner of premises <br /> <br />Address City State/Zip <br /> <br />tS, <br /> <br />Address(es) of Storage Space of Gambling Equipment ,. <br />List all locations where used and unused gambling product is stored. Oo not use a P.O. box number. <br /> <br /> (Attach an additional sheet if necessary.) <br /> Address City <br /> <br />._.~_~ <br /> <br />State/Zip <br /> <br /> ~:-?'.7 ~"5 <br /> <br />I <br />I <br />I <br /> <br />-130- <br /> <br /> <br />