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'FOiR BOARD USE ONLY
<br />Ali—
<br />GAMBLING LICENSE APPLICATION
<br />(Oass A, B, or C)
<br />INSTIRUCTIONS: lei PRINT OiR TYPED
<br />3. a e a
<br />21m Bring completed applicati ' on to local governing body, obtain signature and d t on copies,
<br />and lealve goldenrod copy, Applicant keeps. pink copy and' sends remaining copies to above
<br />address .,
<br />36 Changes in apelication, information must_ be subm-teed wli,th�in 10 days after thg chanw,
<br />Type of Application:
<br />U Class A, Fee $100.00 (Bingo, Raffles, Paddlewheels v Tipboarlds, Plu�ll-Tabs)
<br />0 Class B Fee $ 50.00 (Raffles, Paddlewheels j, Tipboardsq Pull-Tabs)
<br />Class C Fee $ 50 AD (Bingo only
<br />Make checks payable to Minnesota, Charitable Gambling Control Board1l,
<br />III I -
<br />Applicant (official, legal name of' orgenization)
<br />S I JL gl
<br />_HUKA=- SOCIETY OF PJVqJZ3*EY COL117TY
<br />leddr,ess
<br />0 North CleveUnt Avenue
<br />Business Address
<br />11111111111111 11
<br />Cit St VEyezi p
<br />Zhevij
<br />1115 Seulah-Lane
<br />Minn,esiota 55113
<br />Ci,tyt, State, Zip
<br />County
<br />Rardsay
<br />t~ e. Paul M4nnesbta $5608
<br />di
<br />County
<br />Yes
<br />No
<br />Are all gambling activit'
<br />les conducted at
<br />Business Telephone Nuwmbb'e Federal I.I. Number
<br />XX
<br />the above site'. If no, complete a sepa-
<br />61,2 646,-61328 I
<br />41—,6025131.5
<br />rate application form for each site as a
<br />Type. of Organization
<br />J
<br />separate license is issued for each site.
<br />dW"
<br />eternal 0 Veterans
<br />XX
<br />2. Is site located with I n c i ty/town limits?
<br />I I
<br />0 Religious Otheir Nonprofl t Organization 1
<br />,
<br />3* Does organization own the site where
<br />Type of Organi zation Charter XX co=ty
<br />[3 International,
<br />XX
<br />gambling activity will be conducted? If
<br />0 Nat lional 0 State
<br />qo'lf
<br />not attach copy of the lease for the
<br />Number Years in
<br />Number-, of Articles of
<br />site.
<br />Existence in Minnesota)
<br />I ,n�corploration (if incorporated)
<br />oil
<br />essor Name f lease or rent)
<br />114 years
<br />Vii dba, HOLIDAy 1w.; ROSEV3:LLE
<br />ocation Where Articles are Filed
<br />Address
<br />secretaz�yi of' S,ta,tC OWN) or 13to Paul,, WT
<br />2540 North, Cleveland Avenue
<br />Yes
<br />XX
<br />No I s organization have ?
<br />City, State ip
<br />Rosevillet
<br />If XeSf number of active members SIP)
<br />Kinnesota 55113
<br />Has organization been, previou y license-d-
<br />Gam lin -Manager Name
<br />by the Board? If yes date-
<br />RO TSCH11DA
<br />Has license ever been den,31'Ledq suspended
<br />Address
<br />XX or reivokied? I f yes check all that apply:
<br />1115 Boulith Lwm
<br />11 Eheid Sus ended 0 Revoked
<br />C3"Atl St In
<br />I at Z
<br />14. Is organization exempt from payment of
<br />XX
<br />U.S., income tax? If yes, attach, copy of
<br />The 101000 fidelity bond required by Minnesota
<br />letter declaring exemgtion.
<br />S�tatut,ies, 3491*09 has been obtained.
<br />51. Is origan�izatioln tax exempt from payment
<br />Company Name Bond Number
<br />XX
<br />of Minnesota tax�?., If yes, attach, copy of
<br />)f
<br />Fetter dec ari1ng exempt-'ions,
<br />Sta PaLul ri,re A Marine Co. 663NC2798.
<br />
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