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MINNESOTA LAWFUL GAMBLING <br />LG214 Premises Permit Application <br />REQUIRED ATTACHMENTS To LG214 <br />I. If the premises is leased, attach a copy of your lease, Use LG215 <br />Lease for Lawful Gambling Activity. <br />J <br />2. $150 annual premises permit fee, for each permit (non-refundable). <br />Make check payable to "State of Minnesota." <br />' 6/15 Pagel of 2 <br />Annual Fee $150 (NON-REFUNDABLE <br />Mail 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. AP-r-11 � A v,�1 <br />�� License Number: � <br />0 <br />Chief Executive Officer (CEO) 14"-1 <br />Daytime Phone; <br />Gambling Manager: Yr-7 Da time Phone; <br />.. .� <br />6 3- � <br />GAMBLING PREMISES'INFORMATION <br />Current name of site where gambling will be conducted;�� <br />List any previous names for this location: <br />Street address where premises is located; 6, <br />(Do not use a P.O. box number or mailing address.) <br />City: OR Township; County: <br />Zip Code: <br />5�rYc> 3 <br />Does your Organization own the building where the gambling will be conducted? <br />Yes TNO If <br />o4 no., attach LG21'5 Lease for Lawful Gambling Activity, <br />Y <br />A lease is not required, if only a raffle will be conducted. , <br />Is any other organization conducting gambling at this site? Yes No Don't <br />know <br />Note. Bar bingo can only be conducted at a site where another form of lawful gambling is being conducted by the apply in organi- <br />zation ani- <br />zation or another permitted organizationplayed, <br />Electronic games can only be conducted at a site where paper pull -tabs are la ed, <br />Has your organization previously conducted gambling at this site? Yes No [:]Don't know <br />GAMBLING BANK ACCOUNT INFORMATION; MIDST BE IN MINNESOT A <br />Ban Re c041i= 9 .0�k Name. <br />Bank Account Number: 56930—t, <br />Bank Street Address: 17-77 7 �-' 4 vc�—Ikff •°' <br />clty: Av o T e State: MN Zip Code: <br />ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES <br />Address (Do not use a P.O. box number), City: State: Zi C • <br />j p-7 <br />p ode. <br />jqL�l 1*1-1C <br />MN rw.A I <br />MN <br />MN <br />