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LG214 <br /> <br />FOR BOARD USE ONLY <br />FEE <br /> <br />CHECK <br />INITIALS <br />DATE <br /> <br /> Minnesota Lawful Gambling <br />Premise Permit Application - Part I <br /> <br />L/e~Name of (:~rgan[zation / ~ <br />Business A~r~ss of O~afion - S~et or P. O BOx (Do not use address of g~bling manager) <br /> <br /> C,~/,j State Zip Code C,~/u nty <br /> <br /> N.,~.; of chiel executiv.e officer (cannot b~ffrnbling manager) ,., Title <br />· A~lcimss:of-chie~executive officer - Street or P. O. Box <br /> <br />Business phone number <br /> <br />Business phone number <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />Ci~/ State Zip Code Coun~ <br /> <br />i <br />I <br /> <br />Class of Premise Permit Fee <br />[] Class A-- Bingo, Raffles, Paddlewheels, Tipboards, Pull-tabs $200 <br />]~ Class B- Raffles, Paddlewheels. Tipboards, Pull-tabs $125 <br />[] Class C-- Bingo only " $100 <br />L'-'i Class D -- Raffles only $75 <br /> <br />[iii l must be reflected by class of [ <br />iil tt~~on license. <br /> <br />BJmgo Occasions <br /> class A or C, fill in days and beginning amd ending hours of bingo occasions: <br /> No more them seven bingo occasions may be conducted by am organization per week. <br /> <br />Day Beginning/Ending Hours Day Be_ginning/Ending Hours Day <br /> <br />Beginning/Ending Hours <br /> <br /> tO, <br /> <br />__.to, to <br />__.to to to <br /> <br />Status of Premise Permit - check one: ., <br /> <br />[] New premise -- Fill in base organization premise permit number <br />[~enewat of existing premise permit ~ Fill in complete premise permit number <br />[] Previously expired premise permit-- Fill in .complete premise permit number <br /> <br />B -03035"- oo/ <br /> <br />I <br />I <br />i <br />I <br />I <br />I <br />Ii <br />! <br />I <br />I <br />I <br /> <br /> <br />