Laserfiche WebLink
xt FOR BOARD USE ONLY <br /> nesota Charitable Gambling Control Board <br /> 0 Summit State Bank Building <br /> 10 4th Avenue South <br /> y Minneapolis, MN 55415 <br /> ^µ, ` (612) 341-7676 <br /> GAMBLING LICENSE APPLICATION <br /> (Class A, B, or C) <br /> INSTRUCTIONS: 1. PRINT OR TYPE. <br /> 2. Bring completed application to local governing body, obtain signature and date on all copies, <br /> k and leave goldenrod copy. Applicant keeps pink copy and sends remaining copies to above <br /> address. <br /> 3. Changes in application information must be submitted within 10 days after the change. <br /> Type of Application: <br /> ❑ Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull-Tabs) <br /> ' (R Class 8 - Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull-Tabs) <br /> ❑ Class C - Fee $ 50.00 (Bingo only) <br /> Make checks payable to: Minnesota Charitable Gambling Control Board. <br /> Applicant (Official, legal name of organization) Site Address <br /> T. JOSEPH'S SOCIETY FOR THE LITTLE SISTERS 3833 Lexington Avenue North <br /> Business Address OF THE POOR City, State, Zip <br /> 132 Demont Avenue East #341 St. Paul MN 55112 <br /> City, State, Zip County <br /> St. Paul, MN 55117 Ramsey <br /> County - Yes No 1. Are all gambling activities conducted at <br /> Ramsey the above site? If no, complete a sepa- <br /> Business Telephone Number Federal I.D. Number rate application form for each site as a <br /> ( 612) 484-2659 41-1388606 A separate license is issued for each site. <br /> ype of Organization <br /> 2• Is site located within city/town limits? <br /> Faternal C] Veterans X <br /> ® Religious [3 Other Nonprofit Organization 3. Does organization own the site where <br /> Type of Organization Charter gambling activity will be conducted? If <br /> ❑ International C] National ® State X no, attach copy of the lease for the <br /> Number of Years in Number of Articles of site. <br /> Existence (in Minnesota) Incorporation (if incorporated) Lessor ame i ease or rent <br /> 34 2111213/396302 BLUE FOR <br /> Location Where, Article are Filed Address <br /> Ramsey County 3833 Lexington Avenue North <br /> Yes No Does organization have a dues structure? City, State, Zip <br /> x If yes, number of active members St. Paul, MN 55112 <br /> . Has organization been previously licensed Gambling Manager Name <br /> x by the Board? If yes, give date3-13, -85 Jan Sherman <br /> Has license ever been denied, suspended Address <br /> x <br /> or revoked? If yes check all that apply: 2442 North Rice Street #152 <br /> ❑Denied ❑Suspended ❑Revoked City, State, Zip <br /> 4. Is organization exempt from payment of St. Paul, MN 55117_X U.S. income tax? If yes, attach copy of The $10,000 fidelity bond required by Minnesota <br /> letter declaring exem tionpn File Statutes 349.09 has been obtained. <br /> 5. Is organization tax exempt from payment Company Name Bond Number <br /> X of Minnesota tax? If yes, attach copy of exander & Alexander __. 8645389 <br /> letter declaring exemption. <br /> Name of Organization's Officers and Titles <br /> a. Lois Blomberg, Chief Executive Officer C. Patricia Pillsbury, Treasurer <br /> D. Jan Sherman, President d. Ruth Hendrickson, Secretary <br /> CG-00001-01 (12/84) Continued on Page 2 <br /> .. i 1�' 111,l e in 77 <br />