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<br />JUhmesottll Lalliful Gmnblfflf1
<br />JfI:reuuscs Perlldt AppllcaHoll - Pall 1 of 2
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<br />Fon BOARD USI:: otJL.Y
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<br />BASE 11__._____.__
<br />PP II __..__._____u__......
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<br />LG214
<br />17/~g,lllJ
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<br />':1 ~Jp~:.;~jJ!P~li~iitith~~::::IL ~ ;:~.~ ~:} L);l'.~~L; .: . ;':': ~.:.~;' ~:.:.,:~~J~nl:if ~~:~~} ;,:.~.;::; ~:;~:J t~; i.~::~:.i':~ f;0;~f~iEjX.;.;:: ::,~''':':;'"~';': '~::ii' ~:::.~ ,.:~-,:~j. ....,. , . '.
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<br />CIM~ of plolTli!:os pormil
<br />(check OM)
<br />L.I ^ (t~OO) Pull-labs, IIpbo~lIds, paddlnwhonl!\, mlllos, blngl)
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<br />Ii.! B ($250) PuII-t..'lbs, Upbonrds, p:lddlnwhenls, mffle!:
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<br />[] C ($~DO) Bingo only
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<br />[] 0 ($150) Jl:lIf10S oniy
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<br />I.._J
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<br />nonowaf
<br />Olg:mlza.lIo11 bnso IlCf"!lI!';O numbor _.___.. _._,.~_~j_.._.
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<br />PrornH;~s pormll number ____.__.__.____m.._.____._
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<br />f...>. I
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<br />Now
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<br />C('If"'bri Ly Bo\Vl Charit if'S, loe
<br />Bli~i~(i;;;; -Addressol Or gaiiizatlon-: Srreoior r:o Box (Donoiuse iii;J iiddress of yoUi:-gnmbfi,ignmiiiigeij----- n____.___.__.______
<br />(,{llh & N i coJ I (~L S
<br />ciiy" ..______....__m_.__.________.._h_ ---- -..- "--' milin ..-. ....------ ---- Zii;co(iii.---. -.- CounlY .~---.. --.-- [,:iy!filie phone miilibiir"
<br />~JiJ1I\('nl!()Jis. HlI. ~i')/d() lIennep.in ((jIJ .'3(l<)-LI,}'l
<br />ti;i;i~o" o'-cfiii); exe:;li ~veoiiice;: (c;;;,wi bo your ga;;ii;ijng i,ionnlJoij --.-----.-liii,j --- --.-- --.----. ----.-...- iJBYliO~9'" piiono -niimb(;f
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<br />__ __l~I~I]_~...:_ 1~~::,v(2.r ___ C. E. () . ('if.);) Vl ')--HJI (j
<br />n ingo occnsioi!ia. - .-...---------..-.-.- ------.-...----.-----.---.-..--------- --..------------.--.------ ..---.. ........-..-.-..----..--..--..--
<br />If applying for :to class ^ or C pClm.lt. flll tn dny~ and beglnnbll~ tr endIng hours of bIngo occasIons:
<br />No tllOtC th~Hlscvcn lllngo occHstOIt!~1 tlmy be conducted by JiJuT-2U!arl~Jl pcr week.
<br />I:1ny rkglnnll"1g/EndIrJ'~ 1I01ll9 Dny Ikglnnhig/Endlng HOllfll Dny B'~glnnlllg IEIJ(IIJ1~t II 0 III II
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<br />_____... 10__.__ __'_'___'
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<br />_".__. _.___ _._1 0_._.___._.___..
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<br />_..___ .___. _Jo ________.____._
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<br />_____.",.1.0._____...._
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<br />____._____.10____._.__..___ _._
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<br />_____..to__._.__
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<br />If Moga will not be conducl:e<l!, check here
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<br />[ill
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<br />;,ti aHlbnHg:jil:fWin96~.'j.itc:HHiaHuli::'i: .. ..._.........:.',._:_:. .......,;" :.~'?;::t::;'/:<:::::/;. .':"':'~' ". '.':~ ....:'...::.:::.:
<br />r biliil riiost:iEiii!itJiliailtwliOregii;,i6Iiiiil wlll 1;9 co~"duc;IoJ . . . ... hon .~ii~i)i^.jcfrii~!i (&J ;;~i ~~~.~. P6si oijl~i;t;j~~i.i;~;bi);:i -:...:
<br />JiFI!,f1}IhI)....?I1/t,~.~.~~__._._______u_u._ ___ __________.__._ ... _ __ _ __ 0.;Z~..:... -t..l~'-lj. ,<:'''l __l<.:_.__.. . - - .. u_._._ ----
<br />,.; tho rrolllls(l~ locnlfid wilhln dty limits? Cg], Yo'! L:..] No If no, is I.)wnshlp 1:_=] mglmlzfld LJ Unorgnlllz'ld C:J llllillcorpor:llorl
<br />_._,.. _~.__________,_..'_._.__,_,__ ____.._____,.______.._,__ ___.__,_ .~.._. '__' n___ n_._._.n n. ,_ ~___'___'...'_ _ ...__.______,____,._____ --..--.-.,--....--.-----. '-" - ..' ---.-.--..- .'--'.'---
<br />el'( and County wl'ele gnmblinn pro miser. Is lo:alocl Oil Township and County whore gAmbling premlsos Is local('d II outside of city limits
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<br />.l}J.(!ql.-.'/,IJLf~t:.J~..___ __ .._..____._._ __....___ ___.___..__.._.L.__ ____ _._____..___.. ....._______._n.____.__.._._._.____._.__ _._n_...... -------..-.. ...-.......
<br />t1r 1110 llnd addless 01' logal own;)r of plellli~os City Slale lip Codtl
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<br />rlj~~~ ~i ga;fl~atic~~~~ ~;e bl iiifi~ t~~~e if,f~~~i~~~ ~~fbo ~;r~ai1cio~?~~~j~~:~~~".~#J-"tl?2..A!-----.---~ J:~~iL_ 2"-______ - ..-
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<br />If 110, alt.'lch Iho fol'owing:
<br />, · A ~(lrY 01 tho k'llse (form IJJ20::>) wilh I""os fOI ntll'Il!:1 Oll~ yellr.
<br />· n D:lpjl 01 It Sk9tch of Iho noor plllrl with dill1rmsiolls, sllowing whal pollion Is b9ing 1011 sod.
<br />^ Ir:ase and sketch E"\fa holloqlllled lor Clnss 0 nppli.~ti')n!l.
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<br />___.____..________ ________.____________~__.__.___,________.__,_,________.___M________._._____._______..____.._...._'._____
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<br />~~~~!#6.~.i:;~t~~I!~g~..'~~!~~L~ail~~~ik~jg..:.~.~~p.Mn~~!!iS:~q~t~J!!~J~mJ1;~~i;2;:G}jEI......:..~lL._ti.~;~.
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<br />._.j~~r:: i.: 1j,'A'':&'I.l1 f;'M.4J;j~:L!'_._.i)1/v S:l'::.L_;:_r;i..,,?:!.~~jJ 6j9l~L..~ ._____,__
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<br />),7.0,.' i'ljl.w1f( 10 /}1{'(IIC:,1{t'/I::i.-I-' /lltt/ .. ..t;!'-il~}- Tt\/(/c../lJIcr-.r
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