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<br /> 1 ,/(/ (!~
<br /> i
<br />. i Charitable Gambling Control Board FOR BOARD USE ONLY
<br /> J Room N.4 75 Griggs-Midway Building
<br /> 1 I J.Jc:.nH N....., I
<br /> I 1821 University Avenue
<br /> 5t, Paul, Minnesota 55104-3383 --- PAID
<br /> . l6121642-0555 AMT
<br /> CHECK#
<br /> DATE
<br /> GAMBLING LICENSE APPLICATION
<br /> INSTRUCTIONS: - -
<br /> A. Type or print in ink.
<br /> B, Take completed application to local governing body, obtain signature and date on all copiesl 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, Tipboa,ds, Pull-tabs) I I
<br /> J1'>Class B - Fee $ 50,00 IRaffles, Paddlewheels, Tipboards, Pull-tabs) IIiIb dIKft. pII't'-- to:
<br /> DC,sss C - Fee $ 50.00 IBingo only) _~Go_ContnlI_
<br /> DClass D - Fee $ 25,00 IRaffles only)
<br /> YesDNo 1, Is this application for a renewal? If yes, give complete license number []2] . In /) 9,1) <j '.IO(i~ I
<br /> DVesONo 2, If this is not an application for a renewal, has organization been licensed by the Board before? If yes, give base
<br /> license number (middle five digits) I I
<br /> ji/lYes ONo 3. Have Internal Controls been submitted previously? If no, please attach copy.
<br /> 4, APPljCa~ {Official, legal name of organization) 5. Business AddreSS};f Organization
<br /> " €T It 'i-,Fill I< ' ? I _ X. FzM?J..-
<br /> 6, City, Stat~ Zip ounty 8. Business Phone Number
<br /> tl ..H"IZ ( -) rJ
<br /> 9, ype of organization: DFraternal OVetersns J8Religious o Other nonpro it"
<br /> .11 organization is an .. other nonprofit" organization, enswer questions 10 through 13. 11 not, go to question 14. "Other nonprofit" GrganizetionlS
<br /> . must document its tax-exempt status.
<br /> DYes ONo 10. Is organization incorporated 8S 8 nonprofit organization? If yes, give number assigned to Articles or page and
<br /> , book number: I I Attach copy of certificate.
<br /> .
<br /> DYesONo , ,. Are articles filed with the Secretary of State?
<br /> DYes ONo 12. Are articles filed with the County?
<br /> OYesONo 13. Is organization exempt from Minnesota or Federa' income tax? If ves, please attach letter from IRS or Department of
<br /> Revenue declaring exemption or copy of 990 or 990T.
<br /> o Ve.;g!No 14. Has license ever been denied, suspended or revoked? If yes, check all that apply:
<br /> ODenied OSuspended DRevoked Give date; I . . I
<br /> 15. Number of active members 16. Number of years in existence Note: If less than four years, attach
<br /> "'!JV i'L -<<> 1 A/- evidence of three years
<br /> "- existence.
<br /> 17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
<br /> of the organization.
<br /> L{PL rr K. P- s.
<br /> V t C-E ,.?ijiD(i'tJT
<br /> Business Phone Number
<br /> 1 (... I 2..-, -II Cfr; ,Z,lh to '-I L. -Irq?
<br /> 19. Name of establishment where gambling will be 20, Street address (not P.O. Box Numberl
<br /> nducted -- ILl .s-U LLt/b i-J'}03 V
<br /> ., E.
<br /> 21, City, Stete, Zip 22,
<br /> . "tJ Us, 5'51
<br /> CG.OOO 1-02 18/86) White Copy.Board Pink-Local Governing Body
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