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LG214 <br /> <br /> Minnesota/.,await Gambling <br />Premises Permit Application - Part 1 of 2 <br /> <br />FOR BOARD USE ONLY <br /> <br />BASE# <br />PP# <br /> <br />FEE <br /> <br />CHECK <br />INITIALS <br />DATE <br /> <br />'"-'] R~n~W <br /> O~ani:,ation bese license number <br /> <br />New <br /> <br />Premises penmit number <br /> <br />CLass of premises permit <br /> (ca~la,~ k one) <br /> <br />[] A ($400) Pull-tabs, bpboands, paddlewheels, raffles, bingo <br /> <br />[~ B ($25,0) Pull-tabs, iipboards, paddtewheeis, raffles <br /> <br />[] C ($.200) ~,ingo only <br /> <br /> Name of Organization ff <br /> <br /> E~usmess Actciress 6] Or.oanizal~on - S~reet or P. O Box (Do not use me address ol your gambhng manager) <br /> <br /> City Stale Zip CoDe _County <br /> <br /> N~?xe of chiel executive officer (cannot be your gambling manager) TitJe <br /> <br />t3ingo Occasions <br />If app .hrmg for a cia~.~ A or C permit~/ill m days a.nd beginnmtg & ending horn's ofbmgo occasior~: <br /> No more than seven bingo occasions ma3, be conducted by your_o~anization per <br /> !~cginnmgatEnding Hours Day Bcgm_nlng/Ending Hours Day <br /> <br />Daytime phone number <br />Dayame phone number <br /> <br />IX bi=go ~ not be conctuctect, check here <br /> <br />Name ol establisnmenI where gambling will be oonoucte~; Street AO~e~ (~ ~t use a ~sl o~ ~x number) <br /> <br />is me prem~s i~t~ ~Jn ~ limit? ~Yes ~ No If no, Is ~sh~p ~ ~=ed ~ unorg~ed ~ unin~orate6 <br /> <br />City and County where pambting premises is Icx:at~ OR <br /> <br />Name anti adciress of .legal owner of premises City State <br /> <br />Does your organiza6on own l~e builcing where me gaml:fn~g will t:Te c°6~umed? ~'3 YE~; ' .,'---, NO <br /> II no, attach the fo]~owini~: <br /> ' a copy of the lease (form LG2O2) with mn'ns for ~t Wast one yea.-. <br /> <br />Township and County where gambling premises is located if outside of city limi[s <br /> <br />Zip Code <br /> <br />· a copy of ~ sketch of the floor plan with dimensions showing what porlJon is being leased. <br />A lease and sketch are not re .cpired for Class D appiicalions. <br /> <br />Actoress City State Zip <br /> <br /> <br />