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<br />Premises Permit Application - LG214
<br />
<br />Page 2 of 3
<br /> 1/99
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<br />Bingo~casions - for Class A or C Permits
<br />If a-pplying fo~'a~ass A or C permit, enter days and beginning/ending hours of bingo occasions (indicate A.M. or P.M.). No
<br />mere than ten bin~casions may be conducted per week. An occasion must be at least one and one-half hours, not to
<br />exceed four hours, ~ . /.
<br />Day Beginning/Ending Hou-r~....~..~.~Day Beginnin0/Endin?_Hours- . - Day Beginning/Ending Hol~r,~
<br />
<br /> ,to ~ - ' 'to · to
<br />
<br /> to .--- ~"-'""""'"'"~ to to
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<br />.,/
<br />
<br />to --- to
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<br />Gambling .Bank ·Account Information
<br />Bank name
<br />
<br />Bank address
<br />
<br />city
<br />
<br />Bank account number*
<br />
<br /> , State/Zip code,
<br />
<br /> * New organizations: The account number may be obtained and submitted to the Gambling Control Board within
<br /> ten days after you roceive your premises pan'nit
<br />
<br /> "'"'~z" '" ' '"' '.' ' .... ; '" ' "" ";'i .... ' "~?'" '"M'~"-"~">"'" .... "' "~'"" '~'< ..... ""~" '";'"'~'~ ':' ' ..... >'~ '~;'"-"?'~-"~;~"~'
<br />I' Name; address, and title of members authorized to s~gn checks ~om thegambl;~3 account;~he:..-:.3~.i~. -:~:'..
<br /> ,.':" "' ........ · '~ ............ - .................... ' .... '' '" .... ' ~,-'-':- · ' '"~:%~';':"~',~;~'~-'~',','~.":~;'~- '~'~.~'~':~.~,-'-..,'~?':-'~*':~"~¥."~"~:~'.
<br /> or anizat.on s treasurer ma :not handle gambh,, funds.;.,...,,~ ....... . ...... ~.. :. ~;- ~..~ ...~ .... , ............... ~.~ ..............
<br /> ;~'~*.j~,' ' ~¢,f ,.'~:.:;,, ,f~.~ ~' =:.,, '.,~ ...'... =,...'.:?,., ~ :....7~?~::.,>,...'~';.~;,~.~..;;~c5',,..~· T.~:--:;~ ,;-;~'~.~S::,~,,-~.~,:5::;,-.?.,~=.~=~,~,;.'':~--~z.,~.~;t· ;
<br />
<br /> Name Address Title
<br />
<br />Acknowledgment
<br />Gambling site authorization ' '-
<br />I hereby consent that local law enforcement officers, the
<br />board or agents of the board, or the commissioner of
<br />revenue or public safety or agents of the commissioners,
<br />may enter, th .e. Premises to enforce the law.
<br />
<br />Bank records Information
<br />The board is authorized to inspect the bank records of the
<br />gambling account whenever necessary to fulfill
<br />requirements of current gambling rules and law.
<br />
<br />Organization license authorization
<br />I hereby authorize the Gambling Control Board to modify
<br />the class of organization license to be consistent with the
<br />class of permit being applied for.
<br />
<br />Si~h-ature of chief executive &fflcer (Designee may not sign)
<br />
<br />Oath
<br />I declare that:
<br />1. I have read thisapplicafion and all information submitted
<br /> to the board is true, accurate, and complete;
<br />2. all other required information has been fully disclosed;
<br />3. I am the chief executive officer of the organization;
<br />4. I assume, fUll ~esponsii~ility for the fair and lawful
<br /> operation of all activities to be conducted;
<br />5. I will familiarize myself with the laws of Minnesota
<br /> governing lawful gambling and rules of the board and
<br /> agree, if licensed, to abide by those laws and .rules,
<br /> including amendments to them;
<br />6. any changes in application information will be submitted
<br /> to the board and local unit of government within ten
<br /> 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 /> ,_5 oc')
<br /> Date
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