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Minnesota Lawful Gambling <br /> • Gambling License Application - Part 2 <br /> Gambling Premises b Pr <br /> Inf rim <br /> o ati n <br /> 0 <br /> Name of tablishment where q�bling will be conducted Street address (do not use a post office box number) <br /> �P�CN� GcJ�zLs 3 700 SiLyr:-�2 1�4�� �.aA-D <br /> City and County where gambling premises is located OR Township and County where gambling premises is located if outside of any,city limits <br /> CITY COUNTY I TOWNSHIP COUNTY <br /> s7. � �4,rrs�� <br /> Legal owner of gambling premises Name of lessor,if not the legal owner <br /> - 6 MZ m F Sr, /;4,/Th(Vf# <br /> Address of owner City �N� Z Zip Code <br /> 330 S14 V� .[�+e� �� ST. .7 5''' a <br /> Does the organization own the building where the gambling will be conducted? ❑ YES 18f NO (NOTE: Organizations <br /> may not pay themselves rent if they own the building or have a holding company. A lease must be submitted showing rent <br /> payments as zero from gambling funds if the organization's holding company owns the premises. ) <br /> If 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 Manager ormat on <br /> Gamblin manager's na a Date of birth <br /> //r KL-- tj b e�-y IO Z4 9 <br /> Address <br /> ,2 90 4- 2� Ave �(J,�, <br /> City tale Zip code Business phone <br /> �T. Aj eyv v /CIA) 53�4Cp (G(z) 6Z 3 —6 ?3 f <br /> Date that gambling manager became a member of the organization _ 5 / / / 90 <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 /> ................................................................................................................._...... <br /> n <br /> keach lkxmsed gambling premises must have a separate checking accoLL0 <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 Me <br />