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STATE-OFJMINNESOTA <br />GAMBLING CONTROL., BOARD <br />PREMISES PERMIT RENEWAL APPLICATION <br />LG214PPR PRINTED:10/13/94 <br />FORBOARD'USE-,ONLY <br />AMT,xPAID*.'?' z <br />CHECK` NO . <br />LICENSE NUMBER: B-03934-003 <br />EFFECTIVE DATE: 07/01/94 EXPIRATION DATE: 03/31/95 <br />NAME OF ORGANIZATION: Hockey Circle Pines Centennial Youth Assoc <br />GAMBLING PREMISES INFORMATION <br />NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br />Shirley Kayes <br />6810 Lake Dr <br />Lino Lakes 55014 <br />COUNTY Anoka IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br />DOES YOUR ORGANIZATION OWN THIS SITE?: No <br />IF NO, LIST THE LESSOR: <br />Shirlie Moore <br />6810 Lake Dr <br />Lino Lakes MN 55014 <br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR): <br />SQUARE FEET PER MONTH: <br />LESSOR INFORMATION <br />45 AMOUNT PAID FOR RENT PER MONTH: 1000 <br />SQUARE FEET PER OCCASION: 0 AMOUNT PAID PER OCCASION: 0 <br />BINGO ACTIVITY <br />BINGO IS CONDUCTED ON THIS PREMISES: No IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT <br />STORAGE ADDRESS <br />4707 North Rd <br />Circle Pines MN 55014 <br />BANK INFORMATION <br />Circle Pines Credit Union <br />4 S Pine Dr <br />Circle Pines MN 55014 <br />GAMBLING BANK ACCOUNT NUMBER: 15966 <br />ON THE LINES PROVIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST TWO PERSONS <br />AUTHORIZED TO SIGN CHECKS AND MAKE DEPOSITS AND WITHDRAWALS FOR THE GAMBLING ACCOUNT. <br />THE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS. <br />Sharon Kranz <br />7132 Lakeview Lino Lakes MN 55014 Gambling Manager <br />Bradley Erickson 6868 West Shadow Lake Dr. Lino Lakes MN 55014 CEO <br />Neil Reisdorfer 7176 Clear Ridge Centerville MN 55038 Committee Member <br />(BE SURE TO COMPLETE THE REVERSE SIDE OF THIS APPLICATION) <br />THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST <br />