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1987_0413_packet
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1987_0413_packet
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12/5/2011 3:14:25 PM
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Charitable Gambillng Control Board <br />Roorn Nl-475 Griggs-Midway Building <br />182,1 University Avenue <br />St'. P'au,ll, M�innesata 55104-3383 <br />( 1 <br />61 2) 642-,05155 <br />I <br />GAMBLING LICENSE APPLICATION <br />El Yes U No I., Is this application for a renewal? If yes, give complete license number <br />Ye's 0 No 2. If this is not an appilication for a renewal, has organization been licensed by the Board before? If yes, give base <br />lilcense! number fmiddle five digits) Fo f LjLe5 I <br />ElYes CNo - 3., Have Internal Controls been submitted previously?' If no,, please attach copy. <br />4. Applicant (Official, le al name of organization) <br />Y A <br />6. City, State, Zip <br />5. Business Address of Organization <br />B. Business Phone Number <br />( -�- " . ) ?-I, --:!b <br />,> •': 0 1 <br />17. Narne of Chief Executive Officer <br />Business Phone Number <br />*7? <br />18., Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Title e <br />Business Phone Number <br />Lq <br />19�. Name of establishment where gambling will be 20. Street', address (not RO. Box Number) <br />e <br />2,2. County (where gambling premises is I <br />Canary-Applicant <br />conducted <br />2 1. City, State, Zip, located) <br />CG- 0001 -t02 � <br />1 (8,186) White Copy-Board Pink-Local Governing Body <br />
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