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! <br />! <br /> <br />LG214 <br /> <br /> Minnesota Lawful Gambling <br />Premise Permit Application - Part 2 <br /> <br />Name of establishment where gambling will be conducted Sl~eet Address (do not use a p~3~st offic~ box n. umber) <br /> <br />Is I~e premises located wilflin city limits? ['~es [] no <br /> <br />! <br />! <br /> <br />City and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br /> <br /> ! <br />Name and Address of Legal Owner of Premises City <br /> <br />Does ~e o~ization own ~e building where ~e g~bling will be ~n~c~? ~YES <br /> <br />Code <br /> <br />NOTE: Organizations may not pay themselves rent if they own the building or have a holding company. A letter must be sub- <br />mitred showing rent payments as zero trom gambling funds if the organization's holding company owns the premises. The <br />letter must be signed by the chief executive officer.) <br /> If NO, attach the following: <br /> <br /> · a copy of the lease with terms for one year. <br /> · a copy of a sketch of the-floor plan with dimensions, showing what portion is being leased. <br />A lease and sketch are not required for Class D applicantions. <br /> <br />Rent: <br /> <br />For gambling with bingo $ <br />For gambling without bingo $ /~oof~-~ <br /> <br />Total square footage leased <br />Total square footage leased <br /> <br />! <br />! <br /> <br />Address of storage space of gambling equipment <br /> ~ _ ~ddress City State Zip code <br /> <br />(each permitted gambling premises must have a separate checking account) <br />ok Name Bank Account Number <br /> <br />Bank Address City State Zip CoOe <br /> <br /> Name, address, and ~tle of persons au~orized to sign checks and make deposits and withdrawals. <br /> <br /> Name AOOress Title <br /> <br />:Y <br /> <br />37 <br /> <br /> <br />