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Minnesota Lawful Gambling <br />A t <br />6/03 <br />Page 1 of 2 <br />`V L. 1Y IF Grr riacJ rCI11111 pp lca to 1 <br />(see Required Attachments on Page 2) Annual Fee $150 <br />FOR BOARD USE ONLY <br />check tf $ <br />Organization information <br />Organization name <br />Organization license number <br />oCY3ct3 <br />\ \\Q. .�r,,,. C 0_,, @\us. `•\-Nc <br />Name of chief executive officer (CEO) Daytime phone number <br />LI Kdc �.. Fra .� CSt - 4 aSiS <br />Gambling premises information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />\Mo11}-sL� \o.c�, C- Q..,e�� a9co �kcs. S-� . <br />City or township County <br />L\���� Cam I <br />Zip code <br />StV3 <br />Does your organization own the building where the gambling will be conducted? <br />.____Yes _XNo If no, attach LG215 Lease for Lawful Gambling Activity <br />Gambling bank account information <br />Bank name Bank account number <br />w�\\S � &in `a\�\LA4 <br />State /Zip code <br />`M <br />related to this site <br />State /Zip code <br />Bank street address City <br />12,a o w Co. V_ N V\ `\` \\s <br />Address(es) of off -site storage space of gambling equipment <br />(Do not use a P.O. box number) <br />Address l.�/��(i- City <br />Bingo occasions (including bar bingo) <br />Enter day and beginning /ending hours of bingo occasions (indicate A.M. or P.M.). An occasion must be at least 1 -1/2 <br />. hours, not to exceed 4 hours. No more than 10 bingo occasions may be conducted per week. <br />Day Beginning /Ending Hours ax Beginning /Ending Hu <br />�"� U J s /.9, .le)1 to i , ci CJ 'f', rvl to <br />-;= V i / o ', 3,J A r(b / : <br />