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.:-. ~?~:~, Sram ~p ~ ........ ~un~ .......... Da~me ph~e numb~ <br /> <br /> · : .... ... . <br /> Name of ~i (~n~t ~ yo~ ~mbli~ m~ager) ~e , - Day,me phone numbe~ <br /> <br /> C app~ for; A'~ C pre~k ~ m ~ ~d beg~ & en~g ho~ ofb~o occasion: <br /> No mo~ ~ m b~o ~c~io~ my be conduced by your~ per wee~ <br /> Day ~ ~ Horn: }'~'. D~ ~~End~g Hou~ Day <br /> <br /> ~~O~:~ ........... ~.,:.:~::::~::::¥:::: :.:::~¥ ....................................................................................... <br /> ..- ......... . :' -. .... ~:~:3~)~:~:::.~ ============================================ :::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::: <br /> <br /> N~e of es~Nish~ v~bfi~ ~1 ~ ~d~ . ~ ~e~ (~ ~ L se ~ ~st <br /> <br /> Is~premi*sl~tl, ~~~s ~ If~,b~ship ~~ed : un~a <br />~i~ ~d Coun~ ~ I~ ng ~mi~s is I~ OR To. ship ~d Coun~ ~m gambling ~ ~ises is loc <br /> <br /> Na~a~a~r~s~l J~,n~of~m~ ... Ci~ ~ S~ <br /> e buil~ ~m ~e ~m~ing will ~ ~? ~ <br /> <br />Beginning/Ending Hours <br /> <br /> StreeL.Address (de not use a. post office box number) <br /> <br /> r~l organized r--I unorganLzed ~ unincorporated <br /> ng premises is Io~ated OR Township and County where gambling ~emises is located if outside of city limits <br /> <br /> Zip Code <br /> <br />Does <br /> your <br /> , al~ ~h the following: <br /> .: . Ilrr <br /> ~ * a copy of !~ lease (form LG202) wit~ terms for at least one year. <br /> ,.- [ * a oopy of a sketch of the floor plan with dimensions, showing what po~on is being leased. <br /> ~ ~iI fA lease and sketch are not required for Class D applications. <br /> <br /> ....... ~i ....................... ci~ ........... . ....... w':'"", state ........... ap ~ ........................................... <br /> <br /> <br />