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Minnesota Lawful Gambling <br />Premises Permit Application - LG214 <br /> <br />Base # <br />PP # <br />Fee <br /> <br />FOR BOARD USE ONLY <br /> Check # <br /> Initials <br /> Date <br /> <br />Class of Permit <br /> <br />Page 1 of 3 <br /> <br />I <br />! <br /> <br />Check one: <br /> ~ Class A - $400 Pull-tabs, tipboards, paddlewheels, raffles, bingo <br />~ Class B - $250 Pull-tabs, tipboards, paddlewheels, raffles <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 />1/99 <br /> <br />I <br />I <br />I <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) Daytime phone number <br /> <br />Base license 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 />City & county where gambling premises is IdcatedZOR-Township & county where gambling premises is located if outside city IJ~its <br /> <br />Is the premises located within city limits'~Yes [~ No ~] <br /> <br />If KIo, is township: <br /> <br />[] Organized <br />[] Unorganized <br />[--] Unincorporated <br /> <br />Does your organization own the building where the gambling will b~ .?0nducted? <br />J--] Yes ~LNo 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 <br /> <br />City State/Zip <br /> <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling pro.duct is stored. Do not use-a P.O. box number. (Attach 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 -I-FY, you can <br />call the Board by using the Minnesota Relay Service at 1-800-627-3529 and ask to place a call to 651-639-4000. This <br />form will be made available in alternative format (i.e. large pdnt, Braille) upon request. <br /> <br /> <br />