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MINNESOTA LAWFUL GAMBLING 6/15 Page 1 of 2 <br /> LG214 Premises Permit Application Annual Fee $150 (NON—REFUNDABLE) <br /> REQUIRED ATTACHMENTS TO LG214 <br /> 1. If the premises is leased, attach a copy of your lease. Use LG215 Mail the application and required attachments to: <br /> Lease for Lawful Gambling Activity, Minnesota Gambling Control Board <br /> 2. $150 annual premises permit fee,for each permit(non-refundable). 1711 West County Road B, Suite 300 South <br /> Make check payable to"State of Minnesota." Roseville, MN 55113 <br /> Questions? Call 651-539-1900 and ask for Licensing. <br /> ORGANIZATION INFORMATION__ <br /> Organization Name: Brainerd American Le / License Number: 00529 <br /> Chief Executive Officer(CEO) Kevin Stunek 1� Daytime Phone: 218-839-1815 <br /> Gambling Manager: Billy Lowe )aytime Phone: 605-201-3987 <br /> GAMBLING PREMISES INFORMAT <br /> Current name of site where gambling will be conducted: �f; .,a, P! od .040,, <br /> List any previous names for this location: <br /> Street address where premises is located: <br /> (Do not use a P.O.box number or mailing address.) <br /> City: OR Township: County: Zip Code: <br /> 9Ci3#�� kG ( u.iW v ' (1,V, •t) w Le L( DE) <br /> Does bur organization own the building where tlit gambling will be conducted? U <br /> ElYes El No If no, attach LGZ15 Lease for Lawful Gambling Activity. <br /> A lease is not required if only a raffle will be conducted. <br /> Is any other organization conducting gambling at this site? Yes 11NoDon't know <br /> Note: Bar bingo can only be conducted at a site where another form of lawful gambling is being conducted by the applying organi- <br /> zation or another permitted organization. Electronic games can only be conducted at a site where paper pull-tabs are played. <br /> Has your organization previously conducted gambling at this site? Eyes 11No 11Don't know <br /> GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br /> Bank Name: Mid Minnesota Credit Union Bank Account Number: 308038931 <br /> Bank Street Address: 200 S 6th St City: Brainerd State: MN Zip Code: 56401 <br /> ALL TEMPORARY AND PERMANENT OFF-SITE STORAGE SPACES <br /> Address (Do not use a P.O. box number): City: State: Zip Code: <br /> MN <br /> MN <br /> MN <br />