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LG214 <br /> <br /> Minnesota lawful Gambling <br />Premises Permit Application - Part i of 2 <br /> <br />FOR BOARD USE ONLY <br /> <br />BASE # <br />PP# <br />FEE <br /> <br />CHECK <br />INITIALS <br />DATE <br /> <br /> Class of premises permit <br />Renewal (¢~rle~k one) <br /> Organization base license number [] A ($400) Puli-tabs, tipboards, paddlewheels, raffles, bingo <br /> <br /> Premises permit number [] B ($250) Pull-tabs, tipboards, paddlewheels, raffles <br />New [] C ($200) Bingo only <br /> [] D ($150) Raffles only <br /> <br />Name of Organization / <br /> <br />Business Address of Organization - Street or P. O Box (Do not use the address o[ your gambling manager) <br /> <br /> City State Zip Code Co_unty I Daytime phone number <br />Narr~ ot ~ief ex~utive offi~r (~nnot be your gamblin; m~ager) Ti~e ~ Day,me phone number <br />Bingo Occasions <br /> <br />If applying for a class A or C permit, fLU in days and beginning ar ending hours of bingo occasions: <br /> No more than seven bingo occasions may be conducted by your or~anizai;ion per week <br /> Day Beginning/Ending Hours Day Beginning/Ending Hours Day Beginning/Ending Hours <br /> <br /> __ to to .to. <br /> <br />i.~ to ~to <br /> <br />Ifbimgo will not be cOnducted, check here <br /> <br />N..~e 01.,establishment where gambling will be conducted ,/Street Address (do not-use a post office box number) <br /> i~'Z ~/,// ~ /o <br />Is the premises located within city limits? [~Yes r-"l No If no, is tawnship ~ organized I-"'1 unorganized 1~3 unincorporated <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 />Name and address of legal owner of premises City J . S~ ~ I Zip Code <br /> <br />Does your organization own ~e bullring where ~e ga~bling wilt ~ ~nducted? ~ YES ~ NO <br /> <br /> * a ~py of ~ ~ase (~ LG~2) wi~ terms ~r at'~ast one ye~. <br /> * a ~py of a ske~ of ~ fl~r pl~ wi~ dimensions, s~wing what ~on is ~ing lea~d. <br /> A lease a~ s~ ~ ~t m~ired for C~ss D appli~ons. <br /> <br />.............. . ................................. ~_.::::...~: ........ :l.:.::l.. ...... ~l,l.'l''.~l. ............. ~:':.l. ll",.l. ~ ......... ::::;'~ I ....... ' ': ......................... :::::: ........ ::::::::::::::::::::::::::~:: <br />' ' ad,mss ................................... 8'~iE ................... Zi'~'~ ..................... . ............................. { ................... <br /> <br />City <br /> <br /> <br />