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State of Minnesota For Board Use Only <br />Gambling Control Board <br />Premises Permit Renewal Application Amt. Pd <br />Check # <br />,amj.G214PPR Printed:3/1/2002 <br />License Number:B-03800-M Oc .S� Effective Date: 10/1/2000 Expiration Date: 9/30/2002 <br />Name of Organization: Dead Broke Saddle Club <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br />Note: Our records show the premises <br />is located within the city limits <br />�Chimgo-cb-,-MN-550 �a� ���P s�>•� r� <br />County: Chisago. Z.Y /-/,I/ <br />Name of the property owner (If different): <br />*(- CIC� ;7 4�14�1? <br />L <br />Lessor Information <br />Square footage leased per month: <br />Rent paid per month: ©Q© <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br />Storage Information <br />19680 Harrow Ave N <br />Forest Lake, MN 55025 G /-r �� p 3e <br />Bank Information <br />Gambling Bank <br />1650 South Lake St Account Number: 3011821 <br />Forest Lake, MN 55025 <br />On the lines provided below list the name, address and title of at least two persons authorized to sign checks and make deposits and <br />withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br />Name Address City, State, Zip Code Title <br />Michael Burress <br />9243 N 55th St <br />Lake Elmo, MN 55042 <br />Tom Schafflzsen <br />10010 240th St N <br />Scandia, MN 55073 <br />Dave-#ettertvfl <br />8118 181st Ave N <br />Forest Lake, MN 55025 <br />c hti-// - -- <br />I <br />I <br />I <br />(Be sure to complete the reverse side of this application) <br />This form will be made available in alternative format (ie. large print, braille) upon request. Page I of 2 (Continued on Back) <br />