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Minnesota Lawful Gambling <br />Premises Permit Application - LG214 <br /> <br />Class of Permit <br />Check one: <br /> ~-~ Class A - $400 Pull-tabs, tipboards, paddlewheels, raffles, bingo <br /> ~ Class B - $250 Pull-tabs, tipboards, paddlewheels, raffles <br /> <br /> I FOR BOARD USE ONLY <br /> Base # Check # <br />· PP # Initials <br /> Fee Date <br /> <br />' Page ~ oi~ <br /> 1/99 <br /> <br /> ['~ Class C - $200 Bingo only OR bingo and pull-tabs when total gross receipts do not exceed $50.000 per year <br /> [] Class D - $150 Raffles only <br /> <br /> Organization Information <br /> Organization name (as it appears on documentation filed with Base license number <br /> Minnesota Secretary of State or internal Revenue Service) <br /> C <br /> Name of ohief exeoutiv~ o~oer (~nnot be your gambling manmger) Daytime phone number <br /> <br /> Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br /> <br />C~ & ~un~ where gambling premises is lo.ted-OR-To, ship & ~un~ where gambling premises is lo.ted if o~side d~ limits <br /> P~ ~S 0 ~cated within ci~ limits? Ye~ No, ] If "o, is township: ~ Organk,,, <br />is the premises <br /> ~ Unorga~,,zed <br /> ~ Onincomomted <br /> <br />Does your organization own the building where the gambling will be conducted? <br />r-'] Yes J~ 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 lease and sketch are not required for class D applications. <br /> <br /> Name of legal owner of premises Address .. City State/Zip <br />T~ ch ~ · "~~ ~ v~~// <br />IAddress(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not use,a P.O. box number. (Affach an additional <br />sheet if necessary.) <br /> Address City_ ~ <br /> <br />Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. If you use a Ti-Y, you can <br />call the Board by using the Minnesota Relay Service at 1-800-627-3529 and ask to plaoe a call to 651-639-4000. This <br />form will be made available in alternative format (i.e. large pdnL Braille) upon request. <br /> <br /> I <br /> I <br />I <br />I <br />!: <br /> <br />I <br />I <br />I <br /> <br /> I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br /> <br />