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r, . UnarrtauIe Gambling Ccntrol Board )t LO`"° <br />EiI RMII N475 Griggs - Midway Building <br />q 1821 University Avenue <br />St. Paul, MN 55104 -3383 <br />GAMBLING LICENSE APPLICATION <br />(Class A, B, or 0 <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. Changer: In application information must be submitted within 10 days after the charms. <br />Type of Application: <br />{29 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 />5ef vcin is of Mary Inc - <br />Business Address <br />aql{a R i c e 5/1.- S, /f7a <br />City, State Zip <br />St, Pacc1 P. nvt Ss!/3 <br />r <br />County <br />Rgmsc <br />Business Telephocte Number <br />(0 ia) L/83 - q /c2 s' <br />Federal I.D. Number <br />Type of Organization <br />❑ Paternal ❑ Veterans <br />0 Religious ❑ Other Nonprofit Organization <br />Type of Organization Charter <br />❑ International ❑ National oa State <br />' Number of Years in <br />Existence (in Minnesota) <br />7 <br />Number of Articles of <br />Incorporation (if incorporated) <br />R - gI( <br />Location Where Articles are Filed <br />Sec, of S*q * c - M il n ii . <br />Yes <br />No il. <br />�/ <br />Does organization <br />If_yes, number <br />have a dues struct rre�?. e <br />of <br />active members <br />k'' <br />Address <br />-Willa Ric e_ S-t; /S.� <br />2. Has organization been previously licensed <br />by the Board? If yes, give date <br />The $10,000 fidelity bond required by Minnesota <br />Statutes 349.09 has been obtained. <br />Company Name Bond Number <br />Sfq-t'e S irefy CO. . 1g30 <br />,/'" <br />3. Has license ever been denied, suspended <br />or revoked? If yes check all that apply: <br />❑Denied ❑Suspended ❑Revoked <br />✓ <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 Address �` <br />aggo Rice -- <br />Cit State, Zip <br />C , hit e- C a n a c/ et, 1 n yt S-S//7 <br />19 <br />County y <br />net SeY <br />Yes <br />Ji41g <br />No <br />. Are 611 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 />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 />r essor <br />Movers <br />ame i ease or rent) <br />(,tlg rehouse- , Ty, c. <br />Address <br />9</a Rice <br />c-2 <br />City State, Zip <br />Llrr1-C. Conga! , tilr/nui 547/1 <br />Gambling Manager Name <br />T h S I1 em wl a i* <br />Address <br />-Willa Ric e_ S-t; /S.� <br />City, State, Zi <br />7/ <br />St : PO La /t/( Ni <br />