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MINNESOTA LAWFUL GAMBLING <br />LG214 Premises Permit Application <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 />ORGANIZATION INFORMATION, <br />Organization Name: <br />Chief Executive.Officer (CEO) <br />4 /lei /CF <br />/63,4 <br />C <br />Gambling Manager: ,Z 4), <br />• GAMBLING PREMISES INFORMATION <br />Current name of site where gambling will be conducted: <br />List any previous names for this location: <br />6/15 Page 1 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 />Aze `License Number: <br />Daytime Phone: <br />Daytime Phone: <br />e 1p,,, & $ P/z 4t <br />Street address where premises is located: /f� /A4t �� <br />(Do not use a P.O. box numbSr or mallInp address.) <br />City: OR Township: <br />Does your -organization own the building where the gambling will be conducted? <br />ElYes 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? Yes 1No <br />County: <br />C <br />0 - `'T v--6, — 013 <br />�6 r3ag8e)"' <br />ei <br />Zip Code: <br />,1-5703 <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? ®Yes CNo nDon't know <br />GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br />Bank Name: <br />Bank Street Address: <br />Bank Account Number: <br />City: State: MN Zip Code: <br />ALL TEMPORARY AND "PERMANENTOFF-SITE STORAGE SPACES <br />Address (Do not use a P.O. box number): City: , <br />4I>/ 7, i'}vr- <br />State: Zip Code: <br />kit MN 3"5763 <br />MN <br />MN <br />