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<br />.. <br /> <br />" <br /> <br />" <br /> <br />. <br /> <br />. <br /> <br />. <br /> <br />Minnesota Lawful Gambling <br />Organization License Application - LG200A <br />Organization Information <br />Organization name (as It appears on documentation filed with Minnesota Secretary of State or Internal Revenue Service) <br /> <br />For Board Use Only <br /> <br /> <br />u <br /> <br /> <br />e.-v I~ ( <br />Other name(s) used <br /> <br />pf.. <br /> <br />x u VCo <br />Business 10 Number (Minnesota Sales & Use Tax Penn~) <br />(If none, write "None' <br /> <br />Business address of organization - street or P.O. box (The organization address cannot be the same as the gambling manager's <br />address. If your organization does nol have an address, list the home address of your CEO.) <br /> <br />1(" &<.? If-v <br />City <br />,,4vck <br /> <br />c; <br /> <br />W. r!f?OLv If(LL~ f1,.U <br />StatelZip County <br />111 Rfi-i1. HI <br /> <br /> <br />s-n I"L <br /> <br />Business phone number <br /> <br /> <br />( <br /> <br />Officer Information - Chief Executive Officer (CEO) <br /> <br />The CEO: must complete an Organization Officers Affidavit - LG200B <br />is the person responsible for your organization, such as the preSident or commander <br />cannot be your gambling manager <br /> <br />Last name <br /> <br />First name <br /> <br />Middle:s~ <br />Social security number <br /> <br />SLriVE- -2...- <br /> <br />Maiden name <br /> <br /> <br /> <br />A- <br />Business phone number <br /> <br />If your organization is not currently licensed, your CEO and <br />the person who will be the gambling manager must attend <br />the two-day gambling manager seminar before any license <br />can be issued. The gambling manager must pass the exam. <br /> <br />/),} <br /> <br />County <br /> <br />5"5/06 <br /> <br />Officer Information - Treasurer <br />The treasurer: <br />must complete an Organization Officers Affidavit - LG200B <br />is the person who handles non-gambling monies for your organization, such as the bookkeeper or accountant. <br />cannot be your gambling manager . <br />cannot be a signatory on your organization's gambling account <br />The CEO may be the same person as the treasurer, depending on your organization's size and structure. <br />If the CEO is the treasurer, then the CEO cannot be a signatory on your organization's gambling account. <br /> <br />Last name' First name Middle name Maiden name Title Date of birth Business phone # <br /> <br />Date CEO attended gambling manager seminar: <br /> <br />1 <br /> <br />I <br /> <br />Call the Licensing Section at 651-639-4000 to register. <br /> <br />() <br /> <br />Class of Organization License <br />The organization license must reflect all of the fonns of <br />gambling conducted by your organization. <br />Check the box that summarizes the gambling at all of your <br />premises. <br />qg Class A - pull-tabs, bingo, raflles, tipboards, <br />paddlewheels <br />o Class B - pull-tabs, raflles, tipboards, paddlewheels <br />o Class C - bingo or bingo and pul~tabs, if total gross <br />receipts do not exceed $50,000 per year <br />o Class 0 - raflles only <br /> <br />Status of License <br />Check one: <br />(Xl Our organization has never been licensed. <br /> <br />o Previously expired license - list complete license <br /> <br />number: <br /> <br />Page 1 of3 <br />4/99 <br />