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West <br />LG214PPR PRINTED: <br />STATE OF MINNESOTA <br />GAMBLING CONTROL BOARD <br />PREMISES PERMIT RENEWAL APPLICATION <br />FOR BOARD USE ONLY) <br />IAMT PAID <br />CHECK NO. <br />IDATE <br />LICENSE NUMBER: B- 03934 -003 <br />EFFECTIVE DATE: 04/01/97 EXPIRATION DATE: 03/31/99 <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 Keyes <br />6810 Lake Dr <br />Lino Lakes 55014 <br />COUNTY Anoka IS THE PREMISES LOCATED WITHIN THE CITY LIMITS ?: Y <br />LESSOR INFORMATION <br />DOES YOUR ORGANIZATION OWN THIS SITE ?: No <br />IF NO, LIST THE LESSOR: <br />Shirley Moore <br />6810 Lake Dr <br />Lino Lakes MN 55014 <br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR): <br />SQUARE FEET PER MONTH: 30 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 />__. L q 4/.2 o Ncy/es STW <br />eiseler-Pittel5-4B4-55"0"14-6441146- MN -37-5-4"/9 <br />BANK INFORMATION <br />- r -W���► <br />(:47) Fede. <br />..,A <br />1os9 Meadow /a.vis 1 <br />- - - - --- Wiis`f-e gear Lae ,44/t/ 6 -s /a7 <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 />Oa,r y / M � J/e- /� 9S� 13; rcJ1 St 4t./<'es C,.6O <br />Skai^on k,'cul7 713. Lake l'ew 1), Lt►to Lakes /A'9 N' ss of y C apia A101ay <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 />