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<br />Mlinnesol Charitable Gambling Control Board FOR BOARD USE ONLY
<br />900 Summit State Blank Building
<br />3101 4th Avenue South
<br />41 ' Mi"nneiapiolis, MN 5541-5
<br />(612) 341-7676
<br />GAMBLING LICENSIE APPLICATION
<br />(Class A, B, or 01
<br />INSTRUCT I ONSI le PRINT OR TYRE's
<br />2. Bring completed application to local
<br />governing Ibody, obtain signature and date on all copies,
<br />and leave goldenrod copy. Applicant
<br />keeps pink copy and sends remaining copies to above
<br />address.
<br />3` Char es in aovilicatiDn information must be submitted within -10 -djay-s- af ter the chance.
<br />Type of' Application:
<br />10
<br />Class A, - Fee $100*00 (Bingo, , Raffles, Paddlewheels,
<br />Tipboards, Pull -Tabs)
<br />0 Class B Fee $ 510*00 (Raffles,, Paddlewheels, Tipboards, Pull-Tabs)
<br />0 Class C ., Fee $ 50.00 (Bingo only)
<br />Make checks elayable to Minnesota Charitable Gambling Control Board*
<br />Applicant aa. legal name of' organization)
<br />Site Address
<br />"Na Arw",t,
<br />114 ` rv. . • - . . s'
<br />'firdaliF, L A.
<br />Business Address
<br />City, Mate, Zip
<br />r. C; 1 13
<br />I
<br />City, State, Zip
<br />County
<br />County
<br />Yes
<br />No
<br />Are all gambling activities conducted at
<br />..
<br />VV,
<br />the above site? If no, complete a septa-
<br />BusinIess Telephone Numbe
<br />Federal I. Number
<br />rate appl lication form for each site as a
<br />4 1
<br />separate license is issued for each sitr
<br />Type of Organi nation
<br />ratern2s,
<br />al 0 Veterans
<br />Is site located within city/town limits?
<br />0 Religious, 0 Other Nonprofit Organization
<br />Do'
<br />3* Does organization own the site where
<br />Type of Organization Charter t, - -
<br />gambling
<br />gambling activity will be conducted? If
<br />0 International C] National 0 state
<br />nag
<br />nag attach copy of the lease for the
<br />Niumoer of Years in
<br />Number of Articles of
<br />site.
<br />Existence (in Minnesota)
<br />Incorporation (if incorporated)
<br />JL
<br />essor Name ease or f-e-n-0
<br />1,14
<br />[e�:_qc
<br />ta TT
<br />Location Where Articles are, Filed
<br />Address
<br />e�Crp
<br />21 101 rl
<br />Yes
<br />No
<br />Does orglanization have a dues structure?
<br />City, State, Zip
<br />If' 'Xels, number, of active members
<br />'F I lo. ci t. r, 5 .5 12
<br />Has organization been previously licensed
<br />licensed
<br />L
<br />Gambling Manager - _ Na-me-
<br />Gam b
<br />•
<br />by, the Boarid? If yes, give date 4"M
<br />Joan,
<br />70 -0ar"als k i
<br />Has license ever been, denied g, suspended
<br />n9ded
<br />Add re,
<br />Address
<br />or revicked? I f yes check all that apply
<br />apply
<br />111, u I ah- 7P.An e.
<br />0Denied �O Sus eroded 0 Revoked
<br />City, Statet Zip
<br />Cjtyt
<br />4
<br />4. Is oirglanization exempt. from, payment of
<br />SOME1001100 P 0 ta 5 10 P.
<br />d* I Ss, income tax? If -yes, attach copy of
<br />-
<br />The $1,09000 fidelity bond required by Minnesota
<br />letter decl,arin, 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?.1 I,f yiesq attach copy of
<br />�y of
<br />A* 7 Kirine Ci,
<br />letter dieclarin2 exemption,
<br />I
<br />0`0'-00001-01 (12/84) Continued on Page 2
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