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LG214 Premises Permit Application <br />FOR BOARD USE ONLY <br />Check # <br />Organization Information <br />$ <br />f <br />Organization name ( I /C..� License number A 0A� <br />Chiefexecutiveofficer(CEO) Pe- lur L / Daytime phone 6 '5. ' 9? <br />Gambling Premises Information <br />r <br />//1 A i AO' <br />Name of establishment where gambling will be conducted PA /y'/�1u / V S 57aI Z W T/` -- ' <br />Street address where premises is located / / f >" lo A) <br />(Do not use a P.O. box number or mailing address) <br />City � I Township <br />OR <br />I <br />Count ��� <br />"' <br />Z ��� D � <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 />Gambling Bank Account Information (must be in Minnesota) <br />Bank <br />r i nname / / Bank account number � / r,, <br />; -7 / / 6 (� <br />t�'t <br />Bank street address) ) Ci State / coe <br />Pt / ). /4/ ii9 / �'tte l / <br />` j <br />�" ' l <br />All Temporary and Permanent Off -site Storage Spaces <br />(for gambling equipment and records related to this site - must be stored in Minnesota) <br />Address (Do not use a P.O. box nu er) • City State/Zip code <br />6'is : r, ,� : fi e / 1V u/ Mk) S ' <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 hours. <br />pax Beginning /Ending Hours Day Beginning /Ending Hours <br />`, <br />1/0e I 1[00 ?Alto ei‘ m 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 />Annual Fee $150 6/07 Page 1 of 2 <br />—59— <br />