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•r <br />FOR BOARD USE ONLYLQ214»»BASE*PP#_ <br />FEE <br />Minnesota Lauifiil Gambling <br />Premises Permit Application - Part 1 of 2 <br />CHECK <br />INITIALS. <br />DATE_ <br />r\»nmnt - <br />Oi^Mtizition bM« lieanf numbtf O-G/ShO <br />Clast of piafflitas ponnii <br />(efMck oiM) <br />(~| A ($400) Puil-tabs. tiptearOs. paddlawhtolt. raffles, bingo <br />PrwniSM poimtt number B ($250) PuN-tabt, tipboards, paddlewheels. raffles <br />l~l C($200) Bingo only <br />D($150) Raffles only <br />Boi (Do not use tfw addreu of your gambling manager) <br />^Ql________ <br />SUla 2p Code County <br />Nam* of eNafMMuriw*offic«r(canftol be your gambing manager) Tide <br />jTal^ liVilCp. S^r?>‘s\^.gy^-V- <br />ri232acli60»b«y' <br />Oaytimp phoot number <br />Daytime phone number <br />If ai»p^/lng for a nla— a or C pennlt fill in days and beginning & ending hours of bingo occasions: <br />No more than seven bingo occasions may be conducted by yourjusaoizaUfiO per week. <br />Diy Bc^liisdiic/Endlng Hours Day Begtnnlng/Exxllng Hours Day Beginning /Ending Hours <br />.to. <br />Ifbl&go will not bo cenduetede chock boro | \y\ <br />xTTT A’^ABFeamoe iiexrw ^jbouieswabidhr.ebuigfopawBwedbi^ <br />. ^tieet AdiWsa (do not usie a post offioe box number^ <br />wMtinol^lmils? CZlYet ONo IIno,istownahip i—i otganiiad i—i unorganiied □ unincorponled <br />Cl^ end Count) talMraganMne pramlaaa to locaad OR Towmibip and County wheru gambfing premise* is toeatad if outsido of diy imits <br />Nm» aid aSaWof bgN ( <br />AA . <br />'of tigN oanar of ptumiSM <br />iA $1. ^n^r'yit.rx <br />C% . Sua ZpCoda <br />eSSAQAPA/te^ ZAr. A^. <br />Q YES □ NO <br />A <br />SmSJ LiDtiiJ. <br />.y