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Charitable Gambling Control Board
<br />Room N -475 Griggs- Midway Building
<br />1821 University Avenue
<br />St. Paul, Minnesota 55104 -3383
<br />(612) 642 - 0555
<br />GAMBLING LICENSE APPLICATION
<br />FOR BOARD USE ONLY
<br />License Number
<br />PAID
<br />AMT
<br />CHECK#
<br />DATE
<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 />Type of Application:
<br />❑Class A — Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs)
<br />TCIass B — Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) Make checks payable to:
<br />OClassC.— Fee S 50.00 (Bingo only) Minnesota Charitable Gambling Control Board
<br />U1Class,4 Fee $ , 25,90,(Raffles only) ,N,,, �-
<br />L`9Yes ONo 1. Is this application for a renewal? If yes, give complete license number 1.3 - [2' `y / cam'.
<br />❑Yes CINo 2. If this is not an application for a renewal, has organization been licensed by the Board before ?'. If yes, give base
<br />license number (middle five digits)
<br />Yes DNo 3. Have Internal Controls been submitted previously? If no, please attach copy:'
<br />4, I Applicant (Official legal name of organization,) / ` , t 5. Business Address of Organization 7
<br />LI - ce1)A�S `1��L2r::Ir'I�r�,t�l2 ( lip.' I-72 lie .,»:o /iv{ _9.x•1
<br />6. City, State, Zip A 1 l'.':: .' r� 7. County 8. Business phone Number
<br />,.S-,. I ti 4/ . A I,�,� ,15:!.-1// % k A 1 `� e / (4' 1 , ., . 7
<br />9. Type of organization: ❑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 />'Yes No 10.
<br />,. YesONo 11.
<br />SgYes ONO 12.
<br />, VesDNo 13.
<br />❑Yes No 14.
<br />Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and
<br />book number: Attach copy of certificate.
<br />Are articles filed with the Secretary of State?
<br />Are articles filed with the County? ,,,
<br />is organization exempt from Minnesota or Federal income tax? If yes, please attach lefter from IRS or Department of
<br />Revenue declaring exemption or copy of 990 or 990T.
<br />Has license ever been denied, suspended or revoked? If yes, check all that apply:
<br />❑Denied ❑Suspended ❑Revoked Give date: -
<br />15. Number of active members
<br />I ';
<br />16. Number of years in existence
<br />Note: If less than four years, attach
<br />three years
<br />, existence, .
<br />17. Name of Chief Executive Officer
<br />r' . /
<br />. // / /c ,r/
<br />18.
<br />Name of treasurer or person who accounts for other revenues
<br />the organization.
<br />4,7r4 % �� .
<br />l�inI1rt:I
<br />Title
<br />L �... iJ
<br />Title
<br />--1 / , /' .S ti 1 ('. Y'
<br />Business Phone Number
<br />19. Name of establishment where garnbling will be
<br />,cyynducted
<br />20.
<br />Business Phone Number
<br />Street address (not
<br />P0. Box Number)
<br />21. City, State, Zip
<br />, , /I /,ti !
<br />22.
<br />County (where garnbling premises is located)
<br />r .;a /
<br />CG- 0001 -02 (8/86)
<br />White Copy -Board
<br />Canary - Applicant
<br />Pink -Local Governing Body
<br />
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