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State of Minnesota For Board Use OnIv Gambling Control Board Organization License Renewal Application LG200GR Printed: 1 1/15/1999 License Number: A-01485 Effective Date: 4/1/1998 Expiration Date: 3/31/2 000 • Organization Information ........—. North Suburban Youth Roseville MN Sales & Use Tax ermit #: 2328564 1970 Oakerest#118 p Roseville, MN 55113 County: Ramsey Phone Number: (612) 638-4600 Chief Executive Officer Information Richard Matson Date of Birth: 2774 Dellwood Roseville, MN 55113 Phone Number: (612) 633-0156 C-) �. Treasurer Information Date of Birth: _ [} Phone Number: Organization's regularly scheduled meetings are: Last Tuesday from 7:00 PM to 8:00 PM Number of active members over the age of 18: 16 ACKNOWLEDGMENT I DECLARE THAT: I have read this application and all information submitted to the Gambling Control Board; All the information is true, accurate and complete; . The compensation schedule is current and on the with the board; The proof of nonprofit Staffs for the organization is on file with the board; Our organization remains in good standing as anonprofit corporation with the Minnesota $ecremry of State's mice and/or continues to be recognized by the Internal Revenue Service as an income tax exempt organization and,if applicable,our charter remains in good standng with our national organization; All other required information has been filly disclosed; I am the Chief Executive Officer of the organ izat ion; I assume full responsibility for the fair and lawful operation of all gambling activities to be conducted; . I will familiarize myself the the laws of Minnesota governing gambling and rules of the Gambling Control Board and agree,if licensed,to abide by those laws and rules,including amendments to them; A membership list of the organization will be available within seven days after it is requested by the Gambling Control Board; Any changes in application information will be submitted to the Gambling Control Board and the iocdl unit of government within 10 days of the change; A license termination plan will be submitted to the Gambling Control Board within 3 0 days of termination of all Premises Perms xs); The gambling manager is bonded and licensed as required by Minnesota statute;and I understand that failure to provide required information or providing false or misleading information may result in denial or revocation of the li e. t Signature of Chief Executive Officer Date