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Page 1 of 3 <br /> 7/01 <br />Minnesota Lawful Gambling I FORBOARD USEONLY <br />LG214 Premises Permit Application I Cheok # Amo..t __ <br /> Expiratation date <br /> <br />Class of Permit Premises Permit Fee <br /> Dudng 2nd year of <br />Check one Two years organization license <br />[] Class A - Pull-tabs, tipboards, padd~ewheels, raffles, bingo $400 $200 <br />[] Class B - 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 />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 (cannot be your gambling manager) <br /> <br />Organization license number <br /> <br />Daytime phone number, <br />including area code <br /> <br />I Name of establishment where gambling will be conducted <br /> <br />".Street address (do not use a P.O. box number) <br /> <br />Gambling Premises Information <br /> <br />ICity & county where gambling premises is located-OR--Township & county where gambling premises is located if outside city lim <br /> <br /> the premises located within city limits? Yes ~ No E] if No, is township: [] Organized <br /> [] Unorganized <br /> [] Unincorporated <br /> <br />Does your organization own the 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 defined <br /> A Pease and sketch are not required for class D applications. <br /> <br />Name of legal owner of premises Address City State/Zip <br /> <br />:S. <br /> <br />I <br />I <br />I <br /> <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is store~.' Oo not use s P.O. box number. <br /> (Attach an additional sheet it' necessary.) <br /> Address City <br /> <br />State/Zip <br /> <br />-139- <br /> <br /> <br />