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MINNESOTA LAWFUL GAMBLING <br />LG214 Premises Permit Application <br />12/12 Page 1 of 2 <br />Annual Fee $150 (NON REFUNDABLE) <br />Required Attachments to LG214 <br />1. If the premises is leased, attach a copy of your lease. <br />Use LG215 Lease for Lawful Gambling Activity. <br />2. $150 annual premises permit fee, for each permit <br />(non refundable). <br />Make check payable to "State of Minnesota." <br />Mail the application and required attachments to: <br />Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />Questions? Call 651- 639 -4000 and ask for Licensing. <br />Organization Informatio n <br />1. Organization name I/1/LE %7om " R 6M�47. J 2 Q 1A —"tge nse number Z-2 / 9 <br />�•l3 <br />2. Chief executive officer (CEO) C---- . --�---' ,-., Daytime phone (.& \a,aqd <br />3. Gambling manager % r ry�1LC i Daytime phone (157-.45-S9-4& y <br />/ <br />Gambling Premises Information <br />4. Current name of site where gambling will be conducted l r/7X `/t /t' 77 /i1 <br />5. List any previous names for this location <br />`07- , / <br />6. Street address where premises is located ez /c /CC 2 67Ea 31O <br />�/ �- <br />Do not use a P.O. box number or mailing address. in-LE C N u 9 i/ - r N', 5-5117 <br />7. City Township <br />L9%% . LE �A OR <br />County Zip code <br />: S //3 <br />8. <br />Does <br />1 <br />your <br />1 Yes <br />organization <br />own the building where the gambling will be conducted? <br />No If no, attach LG21S Lease for Lawful Gambling Activity. <br />A lease is not required if only a raffle will be conducted. <br />9. Is any other organization conducting gambling at this site? <br />_ <br />Yes X No (Don't know <br />10. Has your organization previously conducted gambling at this site? r <br />Yes No f Don't know <br />Gambling Bank Account Information. Must be in Minnesota. <br />11. Bank name Bank account number <br />a %? K 9 /o(00,z2-/ la7a59f/0G <br />12. Bank <br />F'street gaddress 041-714440,4 City State Zip code <br />are /`1 /C-L 5Th ei/ (-/ E MN 5 //- <br />All Temporary and Permanent Off -site Storage Spaces <br />13. Address (Do not use a P.O. � box number) ACityn State §37 Ziip code <br />3' b f (./ 4)�9 / L- ///LG g4%L/1�164- MN / 7 <br />14. Address (Do not use a P.O. box number) City State Zip code <br />MN <br />15 <br />