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I <br />I <br />! <br />I <br />I <br />i <br />! <br />I <br />I <br />I <br />i <br />I <br />I <br />I <br /> <br />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 /> <br />Renewal <br /> Organization base license number <br /> <br />New <br /> <br />Premises permit number <br /> <br /> (check one) <br />[] A ($400) Pull-tabs, flpboards, paddlewheels, raffles, bingo <br /> <br />[] B ($250) Pull-tabs, IJpboards, paddlewheels, rah]es <br />[] C ($200) Bingo only <br /> <br />[] D ($150) Raffles only <br /> <br />Name of Organization /r'~?~ <br /> <br />Business Address of Organization - Street or P. O Box (Do not use the address of your gambling manager) <br /> <br /> City Slate Zip Co~ <br /> <br />Name ol ~iel ex~utive offi~r (~nnot be your gambling m~ager) Ti~e <br />~i~o occasions <br /> <br />County I <br /> <br />Daytime phone number <br /> <br />Daytime phone number <br /> <br />If applying for a class A or C permit, fill in days and beginning & ending hours of bingo occasions: <br /> No more than seven bingo occasions may be conducted by your organization per week. <br /> Day Beginning/Ending Hours Day Beginning/Ending Hours Day Beginning/Ending Hours <br /> <br />to to <br /> <br />to <br /> <br />__ to ,to <br /> <br /> __to If bingo will not be conducted, check here <br /> <br />Name of establishment where gambling will be conducled Street Address {do not use a post office box number) <br /> <br />Is the premises located within ci~, limits? ~ Yes I--I No If no, is tewnship F'"I organized F"--I unorganized r-"] unincorporated <br /> <br />j~rand County where gambling premises is located OR Township and County where gambling premises is located if outside ol city limits <br />Name and address of legal owner o! premises <br /> <br />! <br />! <br /> <br /> City State Zip Code <br /> <br />Does your organization own ~e builSng where ~e gambling will~ ~nductdd? ~ YES ~ NO <br /> If no, a~ch t~ following: <br /> * a ~py o[ ~ ~ase (Iorm LG~2) wi~ ~rms for at ~ast one ye~. <br /> * a ~py o[ a sketch of ~e fl~r pl~ wi~ dimensions, showing what ~on is ~ing lea~d, <br /> A lease a~ s~ am ~t m~imd for Class D appli~ons. <br /> <br /> Address City State Zip code <br />jo o ,~o. ,,20i~,..T ~-r~. ST'-/~.u rn~u ;~.~/~i <br /> <br /> <br />