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... .... Minnesota �Ch,arita�ble Gam�bling Control Board
<br />'t
<br />FOR BOAR D USE ONLY
<br />900, Summil State Bank Building
<br />31,0 4th Avienue South
<br />Minneapolis, MN 55415
<br />(116121), 3141-676
<br />GAMBLING LICENSE APPLICATION
<br />(Class A, B, or C)
<br />INSTRUCTIONS: Is PRINT OR" TYPE*
<br />241 Bring completed application to local gioilvernin�g body, obtain signature and date on all copies
<br />aundl leave goldenrod copy. Applicant
<br />keeps pink copy and sends remaining copies to above
<br />address.
<br />plication i tion must be —, ...ithin 10
<br />3. C'h nges, in ap nforma submitted w* day§ after the chana
<br />Type of Application:
<br />10
<br />class, A - flee $1DO-00, ('Bingo, Raffles, Paddlewheels,
<br />Tipboardsil IPull-Tabs )
<br />IN Class B - Fee $ 50i. 00 (ftffles� IPaudld.lewheels, Tipboards.,, Pull-Tabs)
<br />01 Class C - Fee $ 510.00 Bingo only)
<br />Make cheers payable, to: Minnesota Charitable Gamblino Control Bolardi.1
<br />Applicant (Official t, legal, name of organization)
<br />Site Address)
<br />rl
<br />i Rosetovin Memo 'al Post No. 542
<br />700 West County Road C
<br />Business Address,
<br />City o State,, Zip
<br />7100 West County Road C
<br />Roseville,, EN 55113
<br />Cityp State,, Zip
<br />Count
<br />Roisevi' I 11e, M 5511 3
<br />Ramsey
<br />County
<br />Riamsey
<br />Yes
<br />No,
<br />1. Are all gambling activities conducted at
<br />Business Telephone Numbe Federial I,,[). Number
<br />( 611 21) 483-3,535 411 _,6o,2114516,
<br />XX
<br />the above site? If no, complete a sepa-
<br />rate application form for each site as a
<br />separate license is issued for each site.
<br />T of O�rigani at,ion
<br />Faternal Vletera
<br />0 ns
<br />XXI
<br />2,Is site located within city
<br />I /town limits?
<br />0' Rell"Ligious 0 Other Nonprof it, Organizati an
<br />.......
<br />3. Does organization own the site where
<br />Type of Organization Charter,
<br />gambling activity will be conducted? If
<br />int, n E] National 0 ate
<br />lNumner - erat,ional St
<br />XX
<br />no, attach copy of the lease for the
<br />of Years in
<br />Numbier of Articles of
<br />site*
<br />Exist,ienice in Minnesota)
<br />40
<br />Incorporation ('if incorporated)
<br />MM
<br />Lessor Name (if lease or rent)
<br />130,3281
<br />n/a.
<br />ILoication Wherie Articles are Fil,ied
<br />Address
<br />Register of Deeds_, RamsM, Co Kinn e q a ta
<br />Yes
<br />No
<br />1. Does organization have a dues structure?
<br />City,, State, Zip
<br />XX
<br />1�
<br />IIIIIIIIIIIIIIIIIIIII yes, number of acti"ve members 83�
<br />Has organization been previously licensed
<br />Gambling Manager Name
<br />XX
<br />by the Board? If yes, give idatel..&r
<br />C1:'Lfton A. Gust 's n, Jr.
<br />Has license ever, been denied, suspended
<br />Address
<br />XX
<br />or revoked? If yes cheick all that apply.-
<br />700 West County Road C
<br />ODenied 0 Suspended ORevoked
<br />City State ,-Zip
<br />4. Is organization exempt from payment of
<br />Roseville., IM 55113
<br />U.S. income tax? If' yes, attach copy of
<br />The $10,000 fidelity bond required by Minnesota
<br />Le'tte'r declare g exemp 4. , an a Attach. #1
<br />Statutes 1.0�9 has been obtained-o
<br />:5. Is organ izati'on tax exempt from payment
<br />Company Name Bond Number
<br />of Minnesota tax?, If yes,,,, attach copy of
<br />United Fire 51 11111111111111154668
<br />1 XX
<br />letter declaring exemp t & onsiAttach. 2
<br />Name of organization's Officers and Titles
<br />a Ssell W. Trout Sir,,,. Commander,
<br />C.1 Alfred J. SI choenthaler Adjutant
<br />b. Leonard B. Hertz 1 st, Vice Ciom=der
<br />d I David, A* Elode Finance Officer
<br />CG-00001 -'01 (12/84) 9 Continued on Page 2
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