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LG214 <br /> <br /> Mirmesota Z4zw. ffi! Gambling , <br />Premises Permit Application - Pa_T-[ <br /> <br />of 2 <br /> <br />FOR BOARD USE <br /> <br />BASE# <br />PP# <br />FEE <br />CHECK <br />IN1T~LS <br />DATE <br /> <br /> Class of premises I:~n'ni~ <br /> (eh e-~k one} <br /> [] A (,$4001 Pull-tabs. dpboards, pa~tewheels, retires, b~ngo <br /> <br /> '~ B ($250) Pull-tabs. tipb~rds, p=.d~ewhe.els, raffles <br /> [] 0{$200~ B/ngo only <br /> <br />Busines~ Address ol Organization - Sl~eel ~ ¢. 0 Box {Do not use the address ot your gambling rr~nager} <br /> <br /> ; <br />Renewal <br /> Org~izalion base license number <br /> <br /> Premises permit number <br /> <br />New <br /> <br /> C~/2~.O~.- ~. Stale Zip Co, de Count/ . Daytime phone number <br /> <br /> Name of ~ief ex,Olive offi~r (~nnol be your gambling m~ager) ' ~e ' Daytime phone number <br /> <br />Bingo Oc~slon~ <br />~ app~g for a cla~ A or C pc~[, ~ ~ da~ ~d bcg~ & cnd~g hou~ of b~o 'occasto~: <br /> Mo morc ~ ~ven b~go ~casions may be cbnducted by your~rEa~tlo~ per week. <br /> Day Bi~End~g Mourn Day Be~End~g Hours Day Bcg~g/Ending Hours <br /> <br />__ to [o ,to, <br /> <br /> __to to. ~ .to <br /> <br /> H'bL~go ~ not ~e conducted, check ~ere [~ <br /> <br />· ' ~ ....... ~ ~v~". ~' ~,~.~ .~,;,,,., ~., ~ ~,. ~- ~,. ~.~t:Z~i~.*',;'~- '~ ~' '~'~'~44~'~i~.~4~:*>':~/',~1:~'~'i~"~4i~,~'~:~:'~'~' ':F~/!'~<,'i*'.,"' ~441~v~4.,:,~:,.-~,. ':~... <br />H~e qf e~blishmenl where flambling w~l[ ~ ~nducled S~t~[ Ad, ross (~ not use a ~s[ oH~ce ~x number) <br /> <br />Is lh~ premiss Iml~wi¢in ci~ limiB? ~s ~ ~o' 1t no. is township ~ ~g~bed ~ unorganized ~ unin~rporaled <br /> <br />Cii./-~ Count,/where g~-nbfing premiss is located OR Township and Counb/where g~mbling premises is located it outside of cib, iimks <br /> <br />~ame and a~ress o~gal~wner o( premise~ - Ci~ Sta~e Zip C~ <br /> <br />Does your org~ni~a~on own Be b~ilding where ~e gambling Will ~ pnducted? ~ ~ES ~O <br /> <br /> I <br /> I <br /> I <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />attach the ¢ollow~ng: <br /> ' a copy of ~ lease (lorm LG:~2) wi~ latins for at least one ye~r. <br /> · a c~p¥ o! a skmch of abe ~cx~- plan wjl:h dimensions, showing what pordon is being lea~ed. <br /> A lease and sketch are not required fox' Class D applications. <br /> <br />I <br />I <br /> <br />Address. of sro.rage space o£. <br />Address City State Zip code <br /> <br />I <br />I <br />I <br /> <br /> <br />