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State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br />LG214PPR Printed: 9/282000 <br />For Board Use Only <br />Amt. Pd <br />Check # <br />Date <br />License Number: B- 03934 -003 <br />Effective Date: 4/1/1999 Expiration Date: 3/31/2001 <br />Name of Organization: Hockey Circle Pines Centennial Youth Assoc <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br />Shirley Kayes <br />6810 Lake Dr <br />Lino Lakes, MN 55014 <br />County: Anoka <br />Note: Our records show the premises <br />is located within the city limits <br />Shirley Moore <br />6810 Lake Dr <br />Lino Lakes, MN 55014 <br />Name of the property owner (If different): <br />Lessor Information <br />Square footage leased per month: <br />Rent paid per month: <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: <br />30 <br />1,000 <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br />ARE' F-RO i�'R G <br />Storage Information <br />99112U />1 �.., s�t- E 3S b) <br />Twin City Federal <br />1059 Meadowlands Dr <br />White Bear Lake, MN 55127 <br />Bank Information <br />Gambling Bank <br />Account Number: <br />5851499148 <br />On the lines provided below list the name, address and title of at least two persons authorized to sign checks and make deposits <br />and withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br />Name <br />Address <br />City, State, Zip Code <br />Title <br />%hhk, 6C1Y0o‹ <br />is( c%nSri4,J,' -- <br />L,),N)L) 1.4, - cc lti <br />ga el) 4:9 GEo <br />Ci411✓ ./'14 Rio V <br />'di() L.i 'Qj `iulik, 04- <br />C P1024-- 24-- sU /y <br />cht 0;:n <br />j l/ mm V L./PS L= <br />S 3(,( LlS L r% . <br />L1,-,i0 141/:e4v (,11"-I <br />3c ep <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. <br />Page 1 of 2 (Continued on Back) <br />