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C.haritable Giambling Control Board <br />Roorn, N-4715 Griggs-Midway Building <br />182'11 University Avenue <br />St. Paul, Minnesota 55104-3383 <br />(612) 642-0555 <br />III � & 0 0 14 Nil 9 <br />4W M <br />■ I <br />k] Yes 0 No 3. Have Internal Controls been submitted previously? If no, please attach copy, <br />9 <br />�161 <br />A pp I i ca, nt (Of f i ci a 1, legal na me of organization) <br />-B-DALE -MENS—CLUB INC <br />City, State,, Zipl'. <br />T. Business Phone Number <br />494.-- -ri-194, <br />15. Nlumbler of activiemembers <br />17. Name lof Chief Executive Officer <br />19'. <br />M <br />P rie,s 1" dent <br />'116. Number of years in existence <br />25 years <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />18. Name of treasurer or person who accounts for other revenues <br />of the organization. <br />ROBERT HOLM <br />Title <br />-Treasurer <br />Business Phone Number <br />1( 6 1,2 4 8 3 -15 2112 3 612 488-3372 <br />Name of establishment,where gambling will be <br />clonducted <br />31-DALE MEN LUB INC. <br />City, State, Zip <br />White Copy-Board <br />21,0. Street address (not P.O. Box Number) <br />22. County (where gambling premises is located) <br />Canary-Applicant <br />Pink-Local Governing Body <br />