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MINNESOTA LAWFUL GAMBLING <br />LG214 Premises Permit Application <br />6/15 Page I of 2 <br />Annual Fee $150 (NON-REFUNDABLE) <br />REQUIRED ATTACHMENTS TO LG214 <br />1, If the premises is leased, attach a copy of your lease, Use LG215 <br />Lease for Lawful Gambling Activity. <br />2. $150 annual premises permit fee, for each permit (non-refundable). <br />Make check payable to "State of Minnesota," <br />Mali the application and required attachments to: <br />Minnesota Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />Questions? Call 651-539-1900 and ask for Licensing. <br />ORGANIZATION INFORMATION <br />Organization Name: Anoka Ramsey Athletic Association <br />License Number: 98049 <br />Chief Executive Officer (CEO) Dustin Reeder Daytime Phone: 612-366-0125 <br />Gambling Manager: Josh Jungling <br />Daytime Phone: 612-860-5616 <br />GAMBLING PREMISES= INFORMATION <br />Current name of site where gambling will be conducted: Acapulco <br />List any previous names for this location: <br />Street address where premises is located: 7988 Sunwood Drive NW <br />(Do not use a P.O. box number or mailing address,) <br />City: OR Township: <br />Ramsey <br />County: <br />Anoka <br />Zip Code: <br />55303 <br />Does your organization own the building where the gambling will be conducted? <br />Yes <br />No If no, attach LG215 Lease for Lawful Gambling Activity, <br />A lease is not required if only a raffle will be conducted. <br />Is any other organization conducting gambling at this site? <br />Yes <br />1' <br />No <br />Don't know <br />Note: Bar bingo can only be conducted at a site where another form of lawful gambling is being conducted by the applying organi- <br />zation or another permitted organization. Electronic games can only be conducted at a site where paper pull -tabs are played. <br />Has your organization previously conducted gambling at this site? <br />Yes <br />I/ <br />No <br />Don't know <br />GAMBLING BANK ACCOUNT INFORMATI <br />N..MINNE-SOTA <br />Bank Name: US Bank <br />Bank Street Address: 129 W Main St <br />Bank Account Number: 104783931306 <br />City: Anoka <br />State: MN Zip Code: 55303 <br />ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES <br />Address (Do not use a P.Q. box number): <br />6100 Bunker Lake Blvd <br />City: <br />Ramsey <br />State: Zip Code: <br />MN 55303 <br />MN <br />MN <br />