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!Charitable Gambling Control Board '1 Board <br />'Mt/ N475 Griggs- Midway Building <br />-1821 University Avenue <br />1St. Paul, MN 55104 -3383 <br />r0R BOARD USE ONLY <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. Changes in application information must be submitted within 10 days after the chanae. <br />Type of Application: <br />INClass 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 />ca (Off/ al al n e off %•or icZpst n <br />MP N g 7 y r 7759 <br />A a 9r„, -n i .t/: (n.' /54/,,/ <br />C St e Zi <br />l p` 3157/ 7 <br />Count <br />Q -D <br />Business Te epho N ber <br />/,,7) AO 227 <br />Feder 1 I.D. Number <br />� /3 ff D <br />Type of Organization <br />❑ Paternal ❑ Veterans <br />Religious ❑ Other Nonprofit Organization <br />Type of Organization Charter <br />❑ International ❑ National State <br />Number of Years in <br />Existence (in Minnesota) <br />t <br />Number of Articles & - / <br />Incorporation (if in r. ed) <br />a ///0213 <br />Location 'e Articles pre Filed <br />Yes <br />No <br />Pr <br />.. Doesoorganization have a dues structure <br />1 's <br />If yes, number of active members . <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 />to / Name jf l •e or repo <br />+r/r,4/ % nisa J� .Lir, <br />2. Has organization been previously licensed <br />by the Board? If yes, give date <br />ddress <br />/3. <br />Has license ever been denied, suspended <br />or revoked? If yes check all that apply: <br />❑Denied ❑Suspended ❑Revoked <br />'p / i �,, /r <br />t ' tic , / /L�...7:7//- <br />Nam: <br />r <br />4. Is organization exempt from payment of <br />U.S. income tax? If yes, attach copy of <br />letter declaring exemption. <br />:/ <br />5. Is organization tax exempt from payment <br />of Minnesota tax? If yes, attach copy of <br />letter declaring exemption. <br />Site Address/ 9-../Ao ece._)ciz . <br />Ci y <br />Stat <br />, Zi .�%J� r <br />9/l ss/, y <br />, <br />County <br />r <br />Yes <br />No- <br />/ <br />V <br />1. Are all ' ambling activities conducted at <br />the above site? If no, complete at sepa- <br />rate application form for each site as a <br />separate license is issued for each site. <br />/ �/ -// <br />2. Is site located within city /town limits? <br />/ <br />/' <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 />to / Name jf l •e or repo <br />+r/r,4/ % nisa J� .Lir, <br />• <br />ddress <br />City/ <br />• .�.► <br />am. ing <br />to .P <br />Manager <br />�/ <br />'p / i �,, /r <br />t ' tic , / /L�...7:7//- <br />Nam: <br />r <br />Addfes: <br />/ <br />�Cit , tate, Zip - <br />f /zu G4- 1 n- Y( <//7 <br />The $10,000 <br />Statutes 349.09 <br />Company <br />f <br />fidelity bond required by Minnesota <br />has been obtained. <br />Bond Number <br />/9 <br />/�me <br />/� / r 027 <br />CG- 00001 -01 (12/84) <br />6 <br />Continued on Page 2 <br />Name of Organization's Officers and Titles <br />J <br />,� <br />/ <br />/ �/ -// <br />• <br />Q:i Y'fc ee, / <br />• <br />.L"1/YCT/ eez - -� <br /><i a/ %� <br />CG- 00001 -01 (12/84) <br />6 <br />Continued on Page 2 <br />