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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 change. g T e 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 />•.plicant (Offici_ , legal name of orga izet on
<br />%V 1W b Y Pa. : `I Pa.f. $S. 1 Y - -
<br />Business Address YYtev. Ce Cv2Ecv:.
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<br />City, State, Zip
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<br />y • •
<br />c \4■G'rnSe`
<br />Business Teleph e Number
<br />((e \2) (QAm t u t te
<br />Federal I.D. Number
<br />ail —T C1S % 517
<br />Type of Organization
<br />❑ Paternal ❑
<br />❑ Religious `1'i,,,`.her
<br />Veterans
<br />Nonprofit Organization
<br />Type of Organization Charter '�,t,
<br />❑ International 0 National yy State
<br />Number-of Years in
<br />Existence (in Minnesota)
<br />25
<br />Number of. Articles of
<br />Incorporation (if incorporated)
<br />\ teY\1
<br />Location 1,4here
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<br />Article are
<br />Fi ed
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<br />Yes
<br />No
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<br />1. D organization have a dues structure?
<br />If yes, number of active members
<br />Address
<br />U i
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<br />7. Has organization been previously licensed
<br />by the Board? If yes, give date
<br />fidelity bon". required by Minnesota
<br />has b eg, bt d
<br />n� .
<br />Name yq \ul Bond Number
<br />,
<br />.
<br />3. Has license ever been denied, suspended
<br />or revoked? If yes check all that apply:
<br />❑Denied ❑Suspended ❑Revoked
<br />4. Is organization exempt from payment of
<br />U.S. income tax? If yes, attach copy of
<br />letter declaring exemption.
<br />5. Is organization tax exempt from payment
<br />of Minnesota tax? If yes, attach copy of
<br />letter declaring exemption.
<br />Site Addres
<br />26\6(0 t'e 3>CreeC
<br />City tate, ,ip
<br />L\ �.G�c'�., \Y.� 5S\ \---A
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<br />Yes
<br />No
<br />1. Are gambling activities conducted at
<br />the ove site? If no, complete a sepa-
<br />rate application form for each site as a
<br />separate license is issued for each site.
<br />Th'J
<br />]\
<br />J
<br />2. Is site located within city /town limits?
<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 1JameZif
<br />(S, \ cs
<br />Address
<br />`Z`\4%
<br />Isaac: oN rent)
<br />\ i ■ Ye uki1i... ' c f
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<br />\,� \c-. \\ree
<br />City, ate, ip
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<br />Camb ing Manager\afs: 2 iG)�
<br />Address
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<br />\3C3 VC-R.-V\ \Ievvw. ,
<br />Ci y State,
<br />The 10,000
<br />Statutes 349.09
<br />Company
<br />Zip Y
<br />1Y\,. 1iA V W SS`t
<br />fidelity bon". required by Minnesota
<br />has b eg, bt d
<br />n� .
<br />Name yq \ul Bond Number
<br />Name of Organization's Of(fiic�errn and Titles
<br />^� \
<br />9:S QNY\ X\\ Sic)
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<br />$
<br />d.
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<br />CC- 00001 - 01'(12/84)
<br />4
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