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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 />INSTRUCTIONS: 1.
<br />2.
<br />3.
<br />Type of Application:
<br />❑ Class A - Fee $100
<br />❑ Class B - Fee $ 50
<br />❑ Class C - Fee $ 50
<br />FOR BOARD USE ONLY
<br />GAMBLING LICENSE APPLICATION
<br />(Class A, B, or C)
<br />PRINT OR TYPE.
<br />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 />Changes in application information must be submitted within 10 days after the chano
<br />.00
<br />. 00
<br />. 00
<br />Make checks payable to:
<br />(Bingo, Raffles, Paddlewheels, Tipboards, Pull -Tabs)
<br />(Raffles, Paddlewheels, Tipboards, Pull -Tabs)
<br />(Bingo only)
<br />Minnesota Charitable Gambling Control Board.
<br />Applicant (Official, legal name f organization)
<br />14A'p. tag8.55'o 4-6s. 1jcoAns e,
<br />Business Addrjess C 0 U QC /L
<br />d2 /D Ah. D/vA$So igLVb.
<br />Ci y, State, Zip �y
<br />imeEV /Cid MA). SS7o26
<br />PJ/YISE 1%
<br />Business T le hone Number
<br />(6 /Z) '9-22 3 4
<br />Federal I.D. Number
<br />/0
<br />4/ —/S43410
<br />Nonprofit Organization
<br />Type of Organization
<br />r] Faternal ❑ Veterans
<br />❑ Religious Other
<br />Type of Organization Charter
<br />❑ International ❑ National SIKState
<br />Number of Years in
<br />Existence (in Minnesota)
<br />Number bf Articles of
<br />Incorporation
<br />Loc �jj'on Where Articles are Filed ��^^,� 4�,7cJLV 27
<br />/tf1/72.-5e J dOV '''',. TT, 74140L —'72
<br />Yes
<br />No
<br />XIf
<br />1. Does organization have a dues structure?
<br />yes, number of active members
<br />3. Does organization own the site where
<br />gambling activity will be conducted? If
<br />attach copy of the lease for the
<br />site.
<br />X
<br />2. Has organization been previously licensed
<br />by the Board? If yes, give date
<br />lif 1 ase or re t)
<br />141/! - VTr1%E
<br />✓
<br />/�
<br />3. Has license
<br />or revoked?
<br />, ❑Denied
<br />ever been denied, suspended
<br />If yes check all that apply:
<br />❑Suspended • Revoked
<br />)/
<br />%�
<br />E. / /TrtE cG,v/9DA A
<br />4. Is organization exempt from payment of
<br />U.S. income tax? If yes, attach copy of
<br />letter declaring exemption.
<br />X
<br />The $10,000 fidelity bond required by Minnesota
<br />Statutes 349.09 has been obtained.
<br />Company Name Bond Number
<br />[JN /TED nee v ensue -LTV SII%
<br />5. Is organization tax exempt from payment
<br />of Minnesota tax? If yes, attach copy of
<br />letter declaring exemption.
<br />Site
<br />V.ENr
<br />Address
<br />e9A1 /Nn) 0267111 gicE Cr,
<br />/l/9V55,UER- .Sa2RETHR✓
<br />City, State, Zip
<br />L / rn -c e,w8Dft in,&J .r-�'//3
<br />County
<br />Yes
<br />Xrate
<br />/�
<br />No
<br />1. Are all gambling activities conducted at
<br />the above site? If no, complete a sepa-
<br />application form for each site as a
<br />separate license is issued for each site.
<br />2. Is site located within city /town limits?
<br />Xno,
<br />3. Does organization own the site where
<br />gambling activity will be conducted? If
<br />attach copy of the lease for the
<br />site.
<br />Lessor
<br />VP,
<br />Name
<br />lif 1 ase or re t)
<br />141/! - VTr1%E
<br />U1 -0Anf
<br />Address
<br />.11/# e /rte in
<br />City, State, Zip
<br />t t77-1—E d9-w9M /fl S53-'//3
<br />Gambling Manager Name
<br />/3E7"TY /%/ /GLER_
<br />Address
<br />4 ass
<br />E. / /TrtE cG,v/9DA A
<br />City, State, Zip
<br />L /TTC -a Lg,Qf3bf. /Ylij 31-117
<br />The $10,000 fidelity bond required by Minnesota
<br />Statutes 349.09 has been obtained.
<br />Company Name Bond Number
<br />[JN /TED nee v ensue -LTV SII%
<br />Name of Organization's Officers and Titles
<br />c. Lveu-,9
<br />/l/9V55,UER- .Sa2RETHR✓
<br />a•%-175N TvL — {?s /oEA
<br />b. 8417)) /1/44.LEk'- V /CE iSESMEJf.c7
<br />.0 K,ALS — 7-RE',95v&s'
<br />CC- 00001 -01 (12/84)
<br />5t
<br />Continued on Page 2
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