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Minnesota Charitable Gambling Control Board
<br />900 Summit State Bank Building
<br />310 4th Avenue South
<br />Minneapolis, MN 55415
<br />(612) 341 -7676
<br />FOR BOARD USE ONLY
<br />GAMBLING LICENSE APPLICATION
<br />(Class A, B, or C)
<br />INSTRUCTIONS: 1. PRINT OR TYPE.
<br />2. Bring completed 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 />address.
<br />3. Changes in application information must be submitted within 10 days after the chance.
<br />Type of Application:
<br />❑ Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -Tabs)
<br />❑ Class B - Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -Tabs)
<br />❑ Class C - Fee $ 50.00 (Bingo only)
<br />Make checks payable to: Minnesota Charitable Gambling Control Board.
<br />Applicant (Official, legal name of organization)
<br />c
<br />5`—r' 01-6 n-F IN l4ry ZGIc,
<br />Business Address
<br />24/-4 R/1ct •S. 11 /5
<br />City, State Zip
<br />5-1. Phu I Pi A •SS7/3
<br />Coun /
<br />ct tm .5 t/
<br />Business Telepho Number
<br />(/e/ .a) 438- q/2 8
<br />Federal I.D. Number
<br />Type of Organization
<br />❑ Faternal ❑ Veterans
<br />Religious ❑ Other Nonprofit Organization
<br />Type of Organization Charter
<br />❑ International [National
<br />2. Is site located within city /town limits?
<br />• State
<br />Number of Years in
<br />Existence (in Minnesota)
<br />Number of Articles of
<br />Incorporation (if incorporated)
<br />Location Where Articles are Filed
<br />Yes
<br />No
<br />1/
<br />1. Does organization have a dues structure?
<br />If yes, number of active members
<br />1/
<br />City, Zip
<br />t- LlAl fr. ei'tr, J Ink, x:57/0
<br />2. Has organization been previously t censed
<br />by the Board? If yes, give date 3//! 8'5'
<br />✓/
<br />3. Has license ever been denied, suspended
<br />or revoked? If yes check all that apply:
<br />❑Denied ❑ Suspended ❑ Revoked
<br />/
<br />V
<br />4. Is organization exempt from payment of
<br />U.S. income tax? If yes, attach copy of
<br />letter declaring exemption.
<br />✓
<br />5. Is organization tax exempt from payment'
<br />of Minnesota tax? If yes, attach copy of
<br />letter declaring exemption.
<br />Site Address ��-7 �'`_,[,
<br />ca SL) G
<br />O !1i t 4i /.
<br />City, State, Zip
<br />1 P& LL /
<br />s /t) t'n et ,510/3
<br />i
<br />Coun)
<br />ri- 01. kin .S t:
<br />Yes
<br />No
<br />1. Are 11 gambling activities conducted at
<br />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 />/
<br />2. Is site located within city /town limits?
<br />v../
<br />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 />Lessor Name (if lease or rent)
<br />Address
<br />c YCQ Jig / c am. �f.
<br />City, State, Zip
<br />St Pa Pa cc/ 1v1 - I 1 n N ,37,57/5
<br />Gambling Manager Name
<br />Pert r ICIG P,' as ,Jttr�/
<br />Address /
<br />we)co I41 Chen, Ebl'I/ ,Q 1
<br />City, Zip
<br />t- LlAl fr. ei'tr, J Ink, x:57/0
<br />The $10,000 fidelity bond required by Minnesota
<br />Statutes 349.09 has been obtained.
<br />y� Company Name n{� j! / Bond Number
<br />F)1c4, lYI der- 1 Ak.4 -crone GO .1 %! tUD GS
<br />Name of Organization's Officers and Titles
<br />-�.{..
<br />,(� I-
<br />c. %�� Irlc-let R;115LJc,167- See,
<br />_
<br />A' --�I--/�'-"
<br />a. DoorDl/\Y/ f . Pres,
<br />/-NOrtrlro
<br />b. 31-1 lSrl € -r YVI a 11 - L/, c c - n es
<br />�1 /_'-
<br />� o r S I� �O a in c� i� c �-
<br />d. r� j J-ire r2 s,
<br />CC- 00001 -01 (12/84)
<br />006
<br />Continued on Page 2
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