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<br />Charitiable Gambling Cohtrol Board
<br />FOR BOARD USE ONLY
<br />�Griggs-Mi A B llding:,
<br />N-47 6 way ul
<br />Uceni*'Nun*1er
<br />1, 821 Universit AvenU ei'.
<br />Y.
<br />.....,_,-....�St.,,Ptit.i[,Minnesdta55.104-3383
<br />AID
<br />P
<br />1-2-1.6142-0 55", APAT_
<br />CHECK#
<br />DATE
<br />APPLICATION
<br />LICENSE
<br />GAMBLING.
<br />f ij
<br />Z J,
<br />4
<br />A
<br />A
<br />TY
<br />n
<br />3
<br />atutd d; ate.-o copies, and - lea'-
<br />Ve 1'copy. Applicant keeps
<br />y,,..o'bt616--s'ig.' n.
<br />'130 ,,
<br />bliki iii'70
<br />Ti e.c,o-,pl,6t6d,�a0pit."c-afton,:to.loebt,00velrni'n.o.obd' an
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<br />s g 0 the. ova I
<br />toipy,4 n od'Inb[t th iddresswith-41' check'
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<br />rh X,
<br />"hico piliA' ill be''ri iijihdd.�
<br />o. applaca
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<br />atio�.
<br />!?:Xypelof A� ic
<br />pt
<br />4 Tr
<br />hi6
<br />08'eds Pult-tabs)
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<br />I li Dic. ig A., Jfoi��'j 00_ W (Bingo- R'aff I" ft-ddle wheels, � " " Tipb
<br />NIS ko checks Pa
<br />KClass]3-i--�:.-`F e 50.001 (Rafflesi, Paddlev�heels,,I'iDbogird��PUII-tabs') yabite to:
<br />C '.6L ote ChadtWe G
<br />(BIngo bril
<br />F 50.00 PMbling Control Bowd
<br />.008" S ee
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<br />8 ;00 (Raffles o
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<br />ly,
<br />er'.
<br />S 0 1.; .',.Is this''660licatio'n
<br />oyd 14 yes, give corrplete license nuriib"
<br />has-
<br />.,2.-. -if for are by the Board before? if yes, give use
<br />0,Y ti been I icensed
<br />newa organiza,
<br />m ber tmiddW- five d'114U
<br />licensid.nui
<br />OyeskNo
<br />Have I' n
<br />ternal Controls been sUbm� ed previously?' If no� please attach copy.
<br />4. I166rit'(0ifficial, legal narrn of organizatio'n)...- 5. Business Addr ess�
<br />of Organization
<br />W4 A&L tr1e, A
<br />QU
<br />6. City,, Statq�zkp 7., C nity 8.' Business Phone Number
<br />VIA 0 10%
<br />9. 'Type of. or g . anizatilion: Fratern& OVeterans QMeligious 'D Other nonprofif,*
<br />If organization is an other nonprofif. organization, answer questiolnis 110through 13. If not,.9pto question 14. "+ether nonprofit"' organizations
<br />must, do ment, its tax-exempt status.-
<br />DYels 0 No- - 10. Is organization il �cor,00rated as a nonprofit- organization? If Yes, give number assigned to Articles or page and -
<br />book, num,ber: Attach copy of certificate.
<br />D Yes E] No 11. Are articles filed W'ith the Secretary of State?
<br />0 Yes IEl No 'I 2.� Are articles filed, with the County? -
<br />11 Yes 0 No 13, Is organiziation exempOrom Minnesota or Federal income tax? If yes, please attach letter from IRS or Departmlenit of
<br />Revenue dieclaring-e'xiemption or cope. of 990 or 990T.'
<br />E1Y6S2%G..1-14. Has license ever been denied,. suspended. or re'voked? If Yes, check all that a
<br />PP
<br />0 Denled' DSuspendied 0 Revoked Give date: E
<br />............ ......
<br />rjd
<br />n
<br />1 ., Nu mber of -active members 1.6.' Number- of years erne wsternce - * Note: If less than four years; attach
<br />Iraq%
<br />of three
<br />Zvi de
<br />erica years
<br />existence..
<br />Vk
<br />17. Namie-of Chief Executive Offil er
<br />Iff "MAIM
<br />Business Phone Number
<br />Nffl095,1,96V=_!11
<br />T
<br />119. Name of establishment where gambling will be
<br />conducted
<br />2 1. -City, State, Zip -
<br />oSFvrLc..r
<br />.-R
<br />16
<br />R/V
<br />White Copy-Board
<br />18., Name of treasurer or person who accounts for other revenues
<br />of the organization.
<br />7-0 e /\
<br />Title oi
<br />L) ,�`14 IF/V )270- Tom P
<br />Business Phone Number
<br />aw C)z
<br />201. Street address (not P.O. Box Number)
<br />IV r Te 4/
<br />2�2. County Where gambling premises is located)
<br />10%,
<br />Pink-Local Governing Body
<br />
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