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r • <br /> Minnesota Lawful Gambling <br /> • Gambling License Application - Part 2 <br /> :...Gam <br /> Gambling Premi se s Information <br /> ..:.:::..::.. <br /> ..::...:::::...: <br /> Name o}ffjj��tablishment where9 am'bling will be conducted Street address (d0 not use a post office box number) <br /> HP'4CN� �tJ�-t Ls 3 700 VC)2 <br /> City and County where gambling premises is located OR Township and County where gambling premises is located if outside of any dry rimits <br /> CITY COUNTY I TOWNSHIP COUNTY <br /> Legal owner of gambling premises Name of lessor,if not the legal owner <br /> -- d�� m F ST. 154VTheVt# <br /> Address of owner City S,ta�tt Zip Code <br /> �3 Ol -/L vet / 4 e� ��J S7-, 7j 5-S"4/r <br /> Does the organization own the building where the gambling will be conducted? ❑ YES 8! NO (NOTE: Organizations <br /> may not pay themselves rent it they own the building or have a holding company. A lease must be submitted showing rent <br /> payments as zero from gambling funds it the organization's holding company owns the premises. ) <br /> ff NO, attach the following: <br /> •a copy of the lease with terms for one year. <br /> •a copy of a sketch of the floor plan with dimensions, showing what portion is being leased. <br /> A lease and sketch are not required for Class D applications. <br /> Rent: <br /> For bingo with other gambling$ Total square footage leased <br /> For gambling without bingo $ O.O O Total square footage leased <br /> • Address of registered storage space: <br /> Address City State Zip Code <br /> Gambling agar Information . .. <br /> Gambling manager's Hartle � Date of birth <br /> Address <br /> City state Zip code Business prione <br /> �T. Avg N OA.) CrQ (le(b) l02 3 —�0 73 Jr <br /> Date that gambling manager became a member of the organization g5 <br /> Date that gambling manager seminar was completed <br /> A$10,000 fidelity bond covering the gambling manager is required by Minnesota law. Provide the following information: <br /> Name of insurance company(do not use agency name) <br /> Bond number <br /> Bank Information .................................................................................................................................................. <br /> o anon <br /> (each 1k*rlsed gambling premises must have a separate checking acccitLnU <br /> Bank name Bank account number <br /> Bank address City State Zip Code <br /> Name,address,and title of members authorized to sign Checks and make deposits and withdrawals <br /> Name Address Title <br />