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---- ~ '~r~"~ ,',.~:~: ~ ~ : ~¥-"'~ .... ;V. '~ : -~ : ':-~:~ ' ! -'" ' ''':: .' '-'~::~ .... · "':" "~ ' <br /> <br />Namea~~-Les~r · ~., ~;~ -. .... , . . . ~drass . .,~ O~y~ip~e Phone ........... ~ ................. <br /> <br />Name of L~ ~t of ~mbli~ Pmml...: .. ~dre. Cirri. ~e__ P~n. . <br /> <br />Name of Org~l;htimi Leasing the Premises (lessee) . .. License Number, if known <br /> <br />The lawful gam~ ling a~Ivity which the organization will conduct is (check all that apply):. . <br /> ~ [~ I b$ k~tiPboard <br /> ~ bingo: ,[~ raffles [---I paddlewheels pu I-ta s <br /> , :., . · . ..' .... .. ~ ..-. . <br /> <br />:Eel:It l'Ttf'Ol~ Ttat;tOl~ (See Rules 7860.0090, Subp 3) . ,. .. · .... ' ...... <br /> . - Claal A end r~ premises permits: . ,'...~ ...... .. ..... ~.-:.:.-. ........... Class B and D premises permits: <br />~' Rent for bingo lind a!l other gambling activities conducted ' _ Rent for gambling activities not including bingo <br /> <br /> during that blilg~: ~sion may not e,x.ceed: <br /> .' $200 for :up ~ 6;0~00 square feet; <br /> $300 for up~ 12, ,~000 square feet; and <br /> $400 for m. o.~e th~n 12,000 square feet. <br /> I Rent to ~e onld nor binao occasion <br /> r <br /> <br />Rent may not b~ baa <br />partlclpanta attdndln <br />An organization.~nay.r <br /> <br />The areaCs)le~:l '! <br /> <br />..' .... . ....~: . <br /> <br />is a maximum of $1000 per month. <br /> <br />Pd on a percentage of receipts, profits from lawful gambling, or on the number of <br /> <br />:)t pay rent to Itself orto any of its affiliates for space used for the conduct of lawful gambling. <br /> <br />iinthe premisasare i~::~::::~ feetby IC-~---'~ feet, for a total of [C) ~C~:3-~ square feet. <br />: · teet by feet, for a total of square feet. <br />~r ' ' feet by ' feet, for a total of square feet. <br /> <br />Shows the Io~tiofl and dimens~fls of the leased areas. <br /> <br />from (hours) <br />from (hours) <br />from (hours) <br />from (hours) <br />from (hours) <br />from (hours) <br />from (hours) <br /> <br />(a.m./p.m.) to · <br />(a.m./p.m.) to <br />(a.m./p.m.) to <br />(a.m./p.m.). to <br />(a.m./p.m.) to <br />(a.m./p.m.) to <br />(a.m./p.m.) to <br /> <br />(a.m./p.m.) on (days of week) <br />(a.m./p.m.) on (days of week) <br />(a.m./p.m.) on (days of week) <br />(a.m./p.m.) on (days of week) <br />(a.m,/p.m.) on (days of week) <br />(a.m./p.m.) on (days of week) <br />(a.m./p.m.) on (days of week) <br /> <br />.L <br /> <br /> <br />