Laserfiche WebLink
<br />..'llll:~.. <br />,. .."".... ~. <br />!}.t ;'.' .:- Q, <br />..:....~OL:~~ <br />-;~... ...~.; <br />';. ,,',.E <br />...;: - ~...~ <br />'J..JW.... <br /> <br />Charitable Gambling Control Bd <br />Rm N-475 Griggs-Midway Bldg <br />1821 University Avenue <br />St. Paul, MN 55104-3383 <br /> <br />rOR BOARD USE ONLY <br /> <br />GAMBLING LICENSE APPLlCA nON <br /><Oass A, B, or C) <br /> <br />INSTRUCTIONS: <br /> <br />1. PRINT OR TYPE. <br />2. Bring completed application to local <br />and leave goldenrod copy. Applicant <br />address. <br />Chan es in a <br /> <br />governing body, obtain signature and date on all copies, <br />keeps pink copy and sends remaining copies to above <br /> <br />lication information must be submitted within 10 <br /> <br />3. <br />~e of Application: <br />~ Class A - Fee $100.00 <br />o Class B - Fee $ 50.00 <br />o Class C - Fee $ 50.00 <br />Make checks a able to: <br /> <br /> <br />h <br /> <br />ch <br /> <br />(Bingo, Raffles, Paddlewheels, Tipboards, Pull-Tabs) <br />(Raffles, Paddlewheels, Tipboards, Pull-Tabs) <br />(Bingo only) <br />Minnesota Charitable Gamblin Control Board. <br /> <br />ApplIcant (Official, legal name of organization) <br /> 'B-D~LE MIENS eLt.l/3 r,.;C <br />Business Address ;I. DALE.. sf. <br /> ;J../OO <br />City, State, Zip . <br />7?05cU/LLk. J Itl rI 5,-~1/3 <br />Coont y K4MSc,/ <br />Business Telephone Number federal 1.0. Number <br />( ~/ Z) 71 ~'1- 9 Fl.? L/I- /33~ a29 <br />e of Organization <br />0 Fraternal o Veterans <br />0 Religious ~her Nonprofit Organization <br />Typ~ of Organization Charter <br />0 International o National ~ State <br />NumOer of Years in Number of Articles of <br />Existence (in Minnesota) Incorporation (if incorporated) <br /> 23 E ??38 <br />LocatIon Where Articles are filed <br /> :5-fAfE OF M I/'IN C 50,14- <br />Yes No . Does organization have a dues str/~ture? <br />x:. number of active members 'j "} <br />X ? Has organization been previously licenseg <br /> by the Board? If yes, Qive date ~ J/'18':> <br /> J. Has license ever been denied, suspended <br /> X or revoked? If yes check all that apply: <br /> OOenied o Suspended ORevoked <br />X 4. Is organization exempt from payment of <br /> U.S. income tax? If yes, attach copy of <br /> letter declarino exemption. <br /> S. Is organization tax exempt from payment <br />X of Minnesota tax? If yea, attach copy of <br /> letter declarino exemption. <br /> <br /> <br />I <br />1/ <br />~/l <br />b~/?AL{ f... <br /> <br />Site Addres~ ;j. ()AL~ ~-f . <br /> . /00 <br />City, State,;tOS/i u~LL ~ I MN ~S/13 <br />Count y ., kA i<1 s~y <br />Yes No . Are all gambling activities conducted at <br />X 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 />x: 2. Is site located within city/town 1 imits? <br />X 3. Does organization own the site where <br /> gambling activity will be conducted? If <br /> no, attach copy of the lease for the <br /> site. <br />lL.essor Name It lease or rent) <br />Address <br />City, State, Zip <br />Gambl1ng Manager Name PE -n~,2s. o,J <br /> Qt::..EqOt<: '/ 11, <br />Address " s+. <br /> 316,0 /~ A c. K'1 k:J/' AI <br />City, State, Zip . S..5:/Z(., <br />S/IO,(Evl r:~ / MtJ <br />The $10,000 fidelity bond required by Minnesota <br />Statutes 349.09 has been obtained. <br /> Company Name Bond Number <br />51-AlE Si-{((E Tf R P-S -2'1'18' cf6 <br /> <br />anlzation's Officers and Titles <br /> <br />CG-OOOOI-Ol (12/84) <br /> <br />c. <br /> <br />13"b {-/-t-;L M - -r~ € A~ 4~ ~IC.- <br />DoN" BLAck See KErN--'y <br /> <br />d. <br /> <br />Continued on Page 2 <br />