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L0ai4 <br />Minnesota Lctwjiil Gambling <br />Premise Permit Application - Part 2 <br />Gambling Premises Information <br />Naim of aatabiiafwnant wihaio gambling wHI ba conductad Sbaat Address (do not use a post office box number) <br />32SiS ________________________ <br />la the pramiiM locaiad within oiy iimita? G no <br />City and County whara gambling piamisaf is locaiad OR Township and County where gambling premises is located it outside of dty limits <br />1 * /fe/u/U/Af/U <br />Nams and Adctess of Legal burner of Prsmtses City State Zip Code <br />Does tw organisation own the buildng where tfte gambling will be conducted? G TES (3^NO <br />NOTE: Organizations may not pay themsalvas rent if they own the building or have a holding company. A letter must be sub- <br />mHtad showing rant paymants as zaro from gambling funds if the organization's holding company owns the premises. The <br />tattar must ba signad by tha chief axacutive officer.) <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 pian with dimensions, showing what portion is being leased. <br />A lease and sketch are not required for Class 0 applicantions. <br />Rant: <br />For gambling with bingo <br />For gambling without bingo $ ^ <br />Total square iootage leased ______ <br />Total square footage leased <br />Address of storege space of gambling equipment <br />Address City <br />^5^7 Coynmk./iSc <br />State <br />nttC <br />Zip code <br />Bank Information <br />(eece pemwuee gamming pnmimt muat neve e eppereie ehiekmg aeeount) <br />BenkNeme <br />Benk Address <br />Bank Account Number <br />Address Ci^ Suie Zip Code <br />Meme, adbhess . and ade ot persons Muthorutd to vgn chocks and maka daposits and wiMrawafs. <br />Name Address Titfe <br />/ ^ iSjfJ ^ <br />TkJkJAjfi <br />T>?aJa ‘7j>y2ax/|g - <br />. / h£A95/r5 J