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Winnesota Lawful Gambling <br />=remises Permit Application - LG214 <br /> <br /> FOR BOARD USE ONLY <br />Base #. Check ~ <br />PP #. I.nitials <br />Fee Date J. <br /> <br />Class of Permit <br />Che~:k one: <br /> ~] Glass A- ,TAO0 Pull-tabs, tipbeards, paddlewheeis, raffles, bingo <br />[] Class B- $250 Pull-tabs, tipbeards, paddlewheels, raffles <br />[] Class C - $200 Bingo only OR bingo and pull-~abs when total gross receipts do not exceed $50,000 per year <br />[] Class O - $150 Raffles only <br /> <br />Page 1 of 3 <br /> 1/99 <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 ma artier) <br /> <br />Base license number <br /> <br />Daytime phone number <br /> <br /> l <br /> <br />Gambling Premises Information <br /> <br /> Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br /> <br />City & c~unty where gambling premises is Iocamd--OR--Township & c~urr~y Where gar~bling premises is located if out~ide cib~ limits <br /> <br /> Is the premises located within city limits?Ye¢ No ~-] If No, is townsl~ip: [] Organized <br /> [] Unorganized <br /> [] Unincorporated <br /> <br />Does your organization own the building where the gambling will be conducted? <br />E~ Yes ~ No If no, attach (1) the appropriate lawful gambling lease form, and <br /> / · <br /> (2) the sketch of all leased areas with dimensions and square footage dearly 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 />List all locations where used and unused gambling product is stored. Do not use a P,O. box number. (Attach an additional <br />sl3eet if necessary.) <br />Address City State/Zip <br /> <br />Questions? Call the Licensing Section of the Gambling Control Beard at 651-639-4000. If you use a Tf'Y, you can <br />call the Board by using the Minnesota Relay Service at 1-800-627-3529 and ask ~ place a call to 651-839-4000. This <br />form will be made available in alternative format (i.e, large pdnt, Braille) upon request. <br /> <br />-113- <br /> <br /> <br />