|
of Board
<br />Charitable Gambling Control Bd
<br />Rm N -475 Griggs- Midway Bldg
<br />1821 University Avenue
<br />St. Peul, MN 55104 -3383
<br />f�, 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 />EJ Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -Tabs)
<br />❑ Class U - 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 />inarsol4 Refi lr1Of -Intro ((Lrs -ccrtk i) 1cif
<br />Business Address
<br />c t +n 9
<br />City, State, Zip
<br />5f . PrtwJ M 14 55 I C 11
<br />County
<br />Ram 5ey
<br />Business Telephone Number
<br />(e,lz)cad- -it?rn
<br />Federal I.D. Number
<br />41 -0q -109
<br />Type of Organization
<br />❑ Faternal ❑ Veterans
<br />❑ Religious W Other Nonprofit Organization
<br />Type of Organization Charter
<br />❑ International ❑ National El State
<br />Number of Years in
<br />Existence (in Minnesota)
<br />1 14
<br />Number of Articles of
<br />Incorporation if incorporated)
<br />Zf 35"3 .` G or st4tr.
<br />Location
<br />Yes
<br />XIf
<br />Where
<br />i •
<br />No
<br />Articles are
<br />G
<br />1. Does organization
<br />yes, number
<br />Filed
<br />as A CC
<br />have a dues structure?
<br />of active members -art)
<br />Address
<br />(29 VI) A cit. C. ter'
<br />City, State, Zip /��
<br />L. [7r/l e4,i4A4 /// /ATM SS7 /7
<br />l ,
<br />x
<br />2. Has organization been previously licensed
<br />by the Board? If yes, give date
<br />7
<br />City, State, Zip
<br />S7- (,ri:.... /? id 5-3. �/7 7
<br />X
<br />3. Has license ever been denied, suspended
<br />or revoked? If yes check all that apply:
<br />❑Denied ❑Suspended ❑Revoked
<br />XU.S.
<br />4. Is organization
<br />income
<br />letter declaring
<br />exempt from payment of
<br />tax? If yes, attach copy of
<br />exemption.
<br />tax exempt from payment
<br />tax? If yes, attach copy of
<br />exemption.
<br />v
<br />/�
<br />5. Is organization
<br />of Minnesota
<br />letter declaring
<br />Site Address
<br />.2 9I ye,
<br />Officers and Titles
<br />Carol N&rtniaH11Sccrc±tl,r Y
<br />7e is c S ix- Ye:-
<br />City, State, Zip
<br />1 - / r—i t c C,4Abia4 74 71//12 C / /7
<br />CountiN
<br />k in ci 17/
<br />Yes
<br />Xrate
<br />No
<br />1. Ai.' 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 />,, /
<br />X
<br />d
<br />2. Is site located within city /town limits?
<br />X
<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 'tit lease or rent)
<br />The) d 'r2 S uJ/ixxr,; ile,:> ; r :Ric
<br />Address
<br />(29 VI) A cit. C. ter'
<br />City, State, Zip /��
<br />L. [7r/l e4,i4A4 /// /ATM SS7 /7
<br />Gambling Manager Name /
<br />6b 4 /ni M1
<br />Address
<br />T9 GsfC s/x,e a1 411C.
<br />7
<br />City, State, Zip
<br />S7- (,ri:.... /? id 5-3. �/7 7
<br />The $10,000 fidelity bond required by Minnesota
<br />Statutes 349.09 has been obtained.
<br />Company Namey4PPt/ L ,$Z Bond Number
<br />Name of Organization's
<br />Officers and Titles
<br />Carol N&rtniaH11Sccrc±tl,r Y
<br />a. Robin La*? P(esMdent
<br />c. y� � 7
<br />)
<br />b . 90 t1,,Ce. csy -ard J \ I is c P ; RQl I ` C i
<br />C a t '
<br />d. Susan D 1/41L1C,'m Son , TfCaSu,2.1l ,
<br />CC- 00001 -01 (12/84)
<br />3
<br />Continued on Page 2
<br />
|