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<br />':'&.~~~ <br />('/V. . '.;:\()\\.t. Ill, ."1(;." .~. <br />iblJ.. ','''', '.''''. n <br />/: . "'-''''. ""-. '.~ <br />rr :~~, "'_~, ...... <br />,.'-0. J!'\'~"r~~:~ <br />~-..,. '&~._:~ <br />, :< <br />."j'.. ., i~.." <br />'71j' - '>;P <br />i~~,i~"~ <br /> <br />Charitable Gambling Control Board <br />Room N-475 Griggs-Midway Building <br />1821 University Avenue <br />St. Paul, Minnesota 551043383 <br />(612) 642-0555 <br /> <br />FOR BOARD USE ONLY <br /> <br />GAMBLING LICENSE APPLICATION <br /> <br />I License Number <br /> <br />PAID <br />AMT <br />CHECK# <br />DATE <br /> <br />INSTRUCTIONS: <br />A. Type or print in ink. <br />B. Take completed application to local governing body, obtain signature and date on all copies, and leave 1 copy. Applicant keeps 1 <br />copy and sends original to the above address with a check. <br />C. Incomplete applications will be returned. <br /> <br />Type of Application: <br />OClass A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull-tabs) <br />btClass B - Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull-tabs) Make checks payable to: <br />OClass C - Fee $ 50.00 (Bingo only) Minnesota Charitable GambUng Control Boa,d <br />CClass D - Fee $ 25.00 (Raffles only) <br /> <br />lXVes UNo "'~~IPr..r",,,,,aI1 IIf yes, give complete license number IT] - I 0011.3 I - I 001 <br /> <br />o Yes DNo 2. If this is not an application for a renewal, has organization been licensed by the Board before? If yes, give base <br /> <br />license number (middle five digits) I I <br /> <br />[jtYes DNo 3. Have Internal Controls been submitted previously? If no, please attach copy. <br /> <br />4. Applicant (Official, legal name of organization) 5. Business Address of Organization <br />Rosetown Memorial Post No. 542 700 West Count Road C <br /> <br />6. City, State, Zip 7. County 8. Business Phone Number <br />Roseville MN 5511.3 Ramee (612 ) 483-.35.35 <br /> <br />!=l Type of organization: o Fraternal ~Veterans []Religious DOther nonprofit * <br />* If organization is an "other nonprofit" organization, answer Questions 10 through 13. If not, go to Question 14. "Other nonprofit" organizations <br />must document its tax-exempt status. <br /> <br />Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br /> <br />book number: I I Attach copy of certificate. <br /> <br />Are articles filed with the Secretary of State? <br /> <br />Are articles filed with the County? <br /> <br />Is organization exempt from Minnesota or Federal income tax? If yes, please attach letter from IRS or Department of <br />Revenue declaring exemption or copy of 990 or 990T. <br /> <br />Has license ever been denied, suspended or revoked? If yes, check all that apply: <br /> <br />DDenied DSuspended DRevoked Give'date: I - - I <br /> <br />DYes DNo 10. <br />DYes DNo 11 . <br />DYes []No 12. <br />DYes DNa 13. <br />DYes glJNo 14. <br /> <br />15. Number of active members 16. Number of years in existence Note: If less than four years, attach <br /> 800 41 evidence of three years <br /> existence. <br />17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues <br /> of the organization. <br /> Tom Bailey Neal Powell <br /> Title Title <br /> Commander Finance Off'icer <br /> Business Phone Number Business Phone Number <br /> ( 612 ) 48.3-.35.35 ( 612 ) 483-.35.35 <br />19. Name of establishment where gambling will be 20. Street address (not P.O. Box Number) <br /> conducted <br />Rosetovn Memorial Post No. 542 700 West County Road C <br /> City, State, Zip 22. County (where gambling premises is located) <br />Roseville, MN 5511.3 Ramsey <br /> <br />CG-0001-02 (8/86) <br /> <br />White Copy-Board <br /> <br />Pink-Local Governing Body <br /> <br />Canary-Applicant <br />