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mmmm <br />LG214 <br />19/5/aoi <br />Minnesota Lawful Gambling <br />Premise Permit Application • Part 1 <br />’ BOARD USE ONXY <br />CHECK _ <br />IMTULS. <br />DATE___ <br />Organization Information <br />Legal Name of Organization / <br />Business Address O# Orgwiization - Street or P 0 Box (Do not use address of gambling manager) <br />/^./O _________________________ <br />QHy Stale up t;ooB y ixiuniy Business phone number <br />iJ^u/n ______________Ua/. y^xM/9^xJ <br />Name of chief executive olfaer (cannot be gambling manager) Tide Business phone number <br />tg. c IA ^ a V “It_______ <br />i- <br />fir, <br />Address of chief executive officer - Street or P O Box <br />Cit^ State Zip Code <br />__________/^aJ.____ <br />County <br />Type of Hgplicxtion <br />Glut of PremlM Permit <br />□ Class A — Bingo, Raffles. Paddlewheels. Tipboards. Pull-tabs <br />0^ Class B — Raffles, Paddlewheels, Tipboards, Pull-tabs <br />□ Class C — Bingo only <br />□ Class 0 — Ragles only <br />7ft# Class of pnmisa parmit <br />must ba raflaetad by class of <br />Iha organization llcanaa. <br />Bingo Occaelone <br />If A OT C. fill In dsyo uid beginning end ending hours of bingo occaslone: <br />No more »Naa eceen bingo occesione mey be conducted by en orglBiMtlBB week. <br />Beglnnlne/Ending Hours Beginning/Ending Hours Oay Beginning /Ending Hours <br />-to_ <br />_to. <br />_to_ <br />to_ <br />w- ■ <br />r’ "r <br />1“ <br />-—r —-.V'- ' ..... . <br />If Binge win net be eendectod. check beie^ <br />Stotns of Premise Permit • cheek one: <br />'V-' <br />V, <br />□ New premiM — Fil in but organization premise permit number _________ <br />Q^enewal of existing premise permit — Rll in complete premise permit number . <br />□ Previousijr expired premise permit — Fill in complete premise permit number^ <br />■-J'C’-' <br />■ V <br />^ Mr OT- OT- <br />y