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I. <br />b <br />Minnesota Lawful Gambhng <br />Premises Permit Application - LG214 <br />Class of Permit <br />Check one; <br />Class A - S400 Pull-tabs, tipboaras, paddlewheels, raffles, bingo <br />FOR BOARD USE ONLY <br />Base U ___ Check# <br />ppn Initials <br />Fee -. Dale <br />Page 1 of 3 <br />1/99 <br />-^^*Class B - S250 Pull-tabs, tipboards, paddlewheels, raffles <br />Class C - S200 Bingo only OR bingo and pull-tabs when total gross receipts do not exceed $50,000 per year <br />I I Class 0 - $150 Raffles only <br />Organization Information <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Internal Revenue Service) <br />Base license number <br />Name of chief executive officer (cannot be' your gambling manager) <br />IT. <br />Daytime phone number <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />City & county where oambhna ofemises is located-OR-Tnwn^in a rrnintv w/horo namhiin^ity & county where gambling premises is localed-OR-Township & county where gambling premises is located if outside city limits <br />Is the premises located within city limits? RL Ye^ <br />lized <br />No If No, is township: Orga- <br />Unorganized <br />Unincorporated <br />yot^^rj^ization own the building where the gambling will be conducted? <br />Yes If no, attach(1) the appropriate lawful gambling lease form, and <br />______________________(2) the sketch of all leased areas with dimensions and square footage clearly defined <br />A lease and sketch are not required tor class u applications. <br />Wameof legal owner of premises Address City State/ZioU6M <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not use a P.O. box number. (Attach an additiona <br />sheet if necessary.) <br />City State/Zio <br />Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. If you use a TTY, you can <br />call the Board by using the Minnesota Relay Service at 1-800-627-3529 and ask to place a call to 651-639-4000. <br />This form '*.ill be made available in alternative format (i.e. large print, Braille) upon request.