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<br /> < I <br /> . FOR BOARD USE ONLY <br /> MINNESOTA DEPARTMENT OF GAMING I License Number , <br /> GAMBLING CONTROL DIVISION I j <br /> Mail Station 3315 PAID <br /> SI. Paul, MN 55146-3315 AMT <br /> . 612/297-5300 CHECK # <br /> DATE <br /> GAMBLING LICENSE APPLICATION <br /> INSTRUCTIONS <br /> A Type or print in ink. <br /> S, Take completed application to local governing body, obtain signature and date on all copies, and leave 1 copy. Applicant keeps 1 <br /> copy and sends original to the above address with a check. <br /> C Incomplete applications may be returned. <br /> D, Enclose license fee with application. <br /> Type of Application: <br /> ~Class A - Fee $200,00 (Bingo. Raffles, Paddlewheels. Tipboards, Pull-Tabs) <br /> o Class B - Fee $125,00 (Raffles, Paddlewheels, Tipboards, Pull-tabs) Make checks payable to: <br /> o Class C - Fee $100,00 (Bingo only) Commissioner of Revenue <br /> o Class 0 - Fee $75,00 (Raffles only) <br /> Check one: jQ 1 A. Organization has never been licensed. <br /> o 1 B. New site - Give base license number ~ <br /> Ole. Renewal of existing license - Give complete license number, 0-1 _----,-!I <br /> CJ 1 D. Change in class of an existing license - Give complete license number. i ! - L -] I <br /> :: YesX3ENo 2, Has organizatio~ ever received a LawJ-0 Gambling Exemption Permit from the Board? If yes. give complete <br /> permit number l -, <br /> ~-~ <br /> = YesXkNo 3 Have Internal Controls been submitted previously on a form provided by the Boardr If no, please attach copy. <br /> 4 ApplIcant (Official, legal name of organization) ! 5. BUSiness Address of Organization <br /> ~<Ld)'_Sl--Umer C,haoter ABWA "'- i- 2030 Glenoaul Ave. <br /> r <br /> 6, City, State, Zip __f County 18. Business Phone Number <br /> . Arden Hill. MN 55112 Ramsey.. 1612 I 633 4138 <br /> _ Type of organization OFraternal OVeterans OReligious XJOther nonprofit <br /> ------,--- "-_. <br /> [J YesJOcNo 10 Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br /> book number i 4 '\ .. "0/4', '0,'6 --' Attach copy of certificate. <br /> _....~ __.__ ~tZ. \., 0 ~---y--- --- <br /> eYes :fkNo 11. Are articles filed With the Secretary of State? <br /> OCYes C No 12 Is organization exempt from Minnesota or Federal income tax? If yes. please attach letter from IRS or <br /> Department of Revenue declaring exemption, <br /> --- --"-- <br /> :: Yes QcNo 13 Has license ever been denied. suspended or revoked? If yes, check all that apply: <br /> o Denied o Suspended o Revoked Give date i <br /> ~ <br /> -_.- I Note' Attach evidence 'of ~- <br /> 14 Number of active members 15. Number of years in existence <br /> 18 9 three years existence. <br /> ._---~- 117. Name of treasurer or person who accounts for other <br /> 16. Nanie of Chief Executive Officer (Cannot be <br /> Gambling Manager) i revenues of the organization (Cannot be Gambling Manager) <br /> Marlyn Damman,Pres. I~~___""' Lee"e <br /> Title <br /> President Title Treasurer <br /> , <br /> Business Phone Number Business Phone Number <br /> ( 612 ) 633 4138 (612 ) 482 7652 <br /> 18 Name of establishment where gambling will be conducted 19. Street address (not P.O. Box Number) <br /> Pot Of Gold I .3 '-7 <.0 <"'Ol'"\f\-O\\\.{ P. >JC_ . <br /> .'0'- City. State, ZIp 121, County (where ga mbltng prem Ises is located) <br /> Arden Hills,MN 55112 I Ramsey <br /> I <br /> CG~0001 ~03 (7/89) White Copy-Board Canary,Applicant Pink-Local Governing Body <br /> Page 1 of 2 <br />