Laserfiche WebLink
<br /> Charitable Gambling Control Board FOR BOARD USE ONLY <br /> . Room N-475 Griggs-Midway Building f Lb:nHNumber I <br /> 1821 University Avenue <br /> 51. Paul, Minnesota 55104.3383 PAID <br /> . (612) 642-0555 AMT <br /> CHECK# <br /> DATE <br /> GAMBLING LICENSE APPLICATION <br /> INSTRUCTIONS: U~Lq~ ~iJw <br /> A. Tvpe or print in ink. <br /> S, Take completed application to local governing body, obtain signature and date on 811 copies, and leave 1 copy. Applicant keeps 1 <br /> copy and sends original to the above address with a check. <br /> C, Incomplete applications will be returned. <br /> Type of Application: <br /> DClass A - Fee $ 1 00,00 (Bingo, Raffles. Paddlewheels, Tipboards, Pull,tabsl <br /> mClass B- Fee $ 50,00 (Raffles, Paddlewheels, Tipboards, Pull.tabs) Make checks payable to: <br /> DClass C - Fee $ 50,00 (Bingo only) Minnesota Charit.t>>e Gernbing Control Board <br /> DClass D - Fee $ 25,00 (Raffles only) <br /> ! OOVllU:JNo 1. Is this application for a renewal? If yes, give complete license number W _ I UiJUO,+ 1.1 Uv;/ I <br /> DYes ONe 2. If this is not an application for a renewal, has organization been licensed by the Board before? If yes, give base <br /> ticense number (middle five digits) I , <br /> OOYes CJNe 3. Have Internal Controls been submitted previously? If no, please attach copy. <br /> 4, ~1~J?fa.lCi~~f-e~f organization) 5. Businesstddress of Organization <br /> 5,-, Iona Lane <br /> 6, City, State, Zip 7, County Ramsey B. ~~iness7hon2 Number <br /> oseville n. 5 113 ( 't 't) 01 <br /> 9, Type of organization: lXFraternal DVeterans DReligious OOther nonprofit- <br /> 4111 organization is an "other nonprofit" organization, answer Questions 10 through 13. tf not, go to Question 14. "Other nonprofit" organizations <br /> . must document its tax-Exempt status. <br /> DYes ONo , o. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Anicles or page and <br /> book number: I I Attach copy of certificate. <br /> DYes CJNo ". Are anicles filed with the Secretary of St8te? <br /> DYes ONo 12. Are articles filed with the County? <br /> ~Yes ONe 13. is organization exempt from Minnesota or Federal income tax? If yes, please anach letter from IRS or Department of <br /> Revenue declaring exemption or copy of 990 or 990T. <br /> DYesXJNo 14. Has license ever been denied, suspended or revoked? If yes, check an that apply: <br /> DDenied OSuspended DRevoked Give date: I . - I <br /> 15. Number of active members , 6. Number of years in existence Note: If less than four years, attach <br /> ICO 54 evidence of three years <br /> existence. <br /> 17, <br /> Title <br /> !I <br /> Business Phone Number Business Phone Number <br /> I ( I <br /> 19, Name of esta~hment Wher~bling will be 20, Street address (not P.O, Box Number) <br /> conducted /.. u e:- 0 3833 NO. Lexington Ave. <br /> 21. City. State, Zip 22. County (where gambling premises is located) <br /> . Arden Hills Mn. 55112 Ramsey <br /> CG-OOOl-o2 {BIBBI White Copy.Board Canary-Applicant Pink. .Local Governing Body <br />