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Minnesota Lawful Gambling <br />LG214 Premises Permit Application <br /> (see Requ,red Attachments on Page 2) Annual Fee $150 <br /> <br /> 8/05 <br />Page 1 of <br /> <br /> FOR BOARD USE ONLY <br /> <br />Check # $ <br /> <br />Organization information <br /> <br />Organizat}Gn name <br /> <br />Name of chief executive officer (CEO) <br /> <br />Gambling premises information <br /> <br />Name of establishment where gambling will be conducted <br /> <br /> Township <br /> <br /> Organization license number . <br /> <br /> Daytime contact phone number <br /> <br />' Not the mailing address. -- -~ <br />~Do not u_~se~ 'P.__O.__bo~x n~umb__er_:_ __ _1 <br /> ~"~' address where premises is located <br /> <br />Zip code <br /> <br />Does your organization own the building where the gambling will be conducted? <br />___Yes __No If no, attach LG215 Lease for Lawful Gambling Activity <br /> <br />Gambling bank account information <br /> <br />Bank street address <br /> /7_77/ u <br /> <br />Bank account number <br /> <br /> State, Zip cede <br /> <br />Address(es) in Minnesota of all temporary and permanent off-site storage space for gambling <br />equipment and records related to this site (may not be stored outside of Minnesota) <br /> Address (Do not u~le ~P.O. ~number) City State/Zip code <br /> <br />Bingo occasions (including bar bingo) <br /> Enter day and beginning/ending hours of bingo occasions (indicate A,M; or P,M,), An occasion may not exceed 8 ho rs, <br /> <br /> O~ Beginning/Endino Hour5 [;),qy Be~innina/Endino Hours J <br /> I <br /> to to <br /> <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> to to <br /> <br />-133- <br /> <br /> <br />