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FOR BOARD USE ONLY
<br />Charlitab�le Gambling Control Board
<br />Rm. N-475
<br />Griggs Modway Bldg
<br />1821, University Avg.
<br />4
<br />St. Paul,, MN 55104-3383
<br />GAMBLING LICENSE APPLICAT10K
<br />(Cl ass N B, or 0
<br />INSTRUCTIONS: 1. PRINT OR IY'PENI
<br />241 Bring completed application to local, goiverning body, obtain signature and date un all copies,
<br />and Ilealve copy. Applicant keeps OW copy and sends remaining copies to above
<br />address
<br />3.. Changes, i.n awli-cation 'information miust be submitted within 10 -days after the change.
<br />Type, or Application:
<br />X Class A IFe,e $100.00 (Bi,ngiolp Raffles, Paddlewheels, Tipboards, Pull-Tabs)
<br />el R, i ds lTabsCla e 0*00 (afFles Paddlewheels, Tipboar )
<br />0' Class C Fee S 510,00 (Bing�io only)
<br />Make checks payable to M�inines,ot,a Charitable Camblina Control Board. .4 v / q VY-- co
<br />icant (Of f'iciail , name of organizati r)
<br />LO,4"
<br />Ij- V-1 U��k *t Z Lo c.
<br />Business 'Addriess
<br />Y', state, Zip
<br />rko)i
<br />coun L ly
<br />IBusines,s 1e,l,ephon�e Number Federal, I.D. Number
<br />0:
<br />)I Ol A-ft
<br />3 _71 --5j 06'" (v V
<br />t/Sop 1(4
<br />T ype of Organization
<br />0 Fraternal Veterans
<br />ED Reliqiious ther Nonprofit Organization
<br />Type, of Organization Charter
<br />International National Mate
<br />'Ntmiler of Mears .in Number of Articles of
<br />Existence (in Minnesota,) Inc �C)i
<br />iorporatic) (if incorporated)
<br />I
<br />dW
<br />Location Where Articles are, Filed
<br />yes j No I1 . Does organization have a dues structure?
<br />number of active members 62wm.
<br />Has organization been previously licensed
<br />by the Board? If' yes, i i,ve date MOW c/- Zrl.�
<br />(Has license ever been denied, suspended
<br />or revoked'? If yes check all thet apply:
<br />OD,enied I 13 us eroded ORevoked
<br />4,. Is organization exempt from payment of
<br />U,S, income tax? I f yes, attach copy of
<br />letter declaring exemption.,
<br />NNNNNNNNNNNd%w~
<br />5. Is, organization tax exempt from payment
<br />of Minnesota tax? If yes, attach copy of
<br />V/00000 0,
<br />letter declaring, exemption.
<br />Address
<br />City, State, Zip
<br />Name of Ornanization's Officers and Titles
<br />M
<br />rr-,nnn,nii - ni ej?lp;,� Cnntinued on Page ?,
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