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I N S T R U'C T 10 N 5 1,, PRINT OR TYPE,10 <br />2 di l Bring co;npleted application to local governing body, obtain signature and date on all copies, <br />and leave goldenrod copy. Applicant keeps pink copy and sends remaining copies to above <br />adidresso <br />.3. Changes in application information must be submiitted within 10 -day-g. after the change. <br />Type of Application: <br />101 <br />Class A Fee $100q,00 03ingio, Raffles, P,addlewheels,, <br />Tipbloards, Pull-Tabs) <br />Q Class B Fee S 50.00 (Raffles, Paddlewheels, Tipboardst Pull-Tab s )i <br />I0 Class C Fee, $, 50.010 (Bingo only) <br />Flake cheicks Layable to Minnesota Charitable GambliM Control Board. <br />Site Address <br />Applicant (Official,,, legal name of organization) <br />r_nrnjLs_1Cbr.i_sti rhiirrh <br />Busindi Address <br />Fn* Avp <br />City, State, Zip <br />IAA!] <br />City, , State, Zip <br />T? <br />Cotinity <br />County <br />P VIM <br />Yes <br />CPU <br />No W <br />Are all gambling activities conducted at <br />P -n Mi <br />the above site? I f no, complete a sepa- <br />Business Telephone Nunber <br />Federal I.D. Number <br />rate application form for each $ite s a <br />n <br />separate license is issued for each sit <br />Type of Orig�anizati,oni <br />6�,� <br />0 Fate rnal 0 Vetierans <br />X <br />2. Is site located with incity/town limits? <br />E� Religious [3 Other Nonprofit, Organization <br />3. Does organization own the site where <br />Type of Organization Charter <br />gambling activity will be conducted? If <br />Cj International National tate <br />PAclan <br />no, attach copy of the lease for the <br />Niuminer of Years in <br />Number of Articles of <br />site. <br />Existence (in (Minnesota) <br />A <br />Incorporation (if incorporated) <br />liessoll Name (if lease or rents <br />essor <br />r <br />A 1; <br />Location Where Articles, are Puled <br />� <br />Address 1 NJA <br />P, <br />Yes <br />mepu <br />W-31—to <br />CQUQtV Re-r-ardpar. <br />IDoes 6rganization have a dues structure? <br />City, State Zip <br />If yes number of active members <br />Has organization been) e <br />prviously licensed <br />Ga rn b j g <br />l n�i Manager Name <br />< <br />41 <br />by the Board? If y�es i <br />,i gve date. <br />AA@yers <br />Has license ever been denied, suspended <br />Address <br />or r,ievloked? If' yes check all that apply- <br />0 <br />2214 Scudder Street <br />y <br />DDenied I U sl enuded Revoked <br />City,, State, Zip <br />4s. Is organization exempt from payment of <br />lqte El 11 minne Rntq MOB <br />X <br />U.,S. income tax? If yes I attach copy of <br />'The $,1,0,0010 fid lity bond required by Minnesota <br />A <br />letter dieclarim. exemption. <br />Statutes 349.09 has been obtained. <br />5. Is organization tax exempt from payment <br />Company Name Bond Number <br />of Minnesota tax? If yesy attach copy of <br />lietter declaring I <br />Archdiocese Of Stom._P2WL $100,000 Employee <br />I-- <br />exemption. <br />TP.Mr-M <br />mwmt "..11.1 1 R-i I <br />4TS <br />CG-00001-01 (121/814) <br />Continued on Page 2 <br />