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'C h ritable Gambli%. Control Board 31 Board <br />RM# N475 Griggs- Midway Building <br />1821 University Avenue <br />St. Paul, MN 55104 -3383 <br />I <br />OR 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, <br />and leave goldenrod copy. Applicant keeps pink copy <br />address. <br />3. Changes in application information must be submitted <br />obtain signature and date on all copies, <br />and sends remaining copies to above <br />thin 10 days after the change, <br />Type 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 />Applicant (Official, legal name of organization) <br />HUMANE SOCIETY OF RAMSEY COUNTY <br />Business Address <br />1115 Beulah Lane <br />City, State, Zip <br />St. Paul, Minnesota 55108 <br />County <br />Ramsey <br />Business Telephone Number <br />( 612) 645 -PETS <br />Federal I.D. Number <br />41- 6025135 <br />Type of Organization <br />❑ Faternal ❑ Veterans <br />❑ Religious Bother Nonprofit Organization <br />Type of Organization Charter XX County <br />❑ International ❑ National ❑ State <br />Number of. Years in <br />Existence (in Minnesota) <br />115 years <br />Number of Articles of <br />Incorporation (if incorporated) <br />681 -NPA <br />Location Where Articles are Filed <br />Secretary of State (MN), St. Paul, Minnesota <br />Yes <br />No <br />1. Does organization <br />If yea, number <br />have a dues structure? <br />members e <br />of active <br />XX <br />City, State, Zip <br />St. Paul, Minnesota 55108 <br />2. Has organization <br />by the Board? <br />been previously licensed <br />If date <br />yes, give <br />XX <br />3. Has license ever been denied, suspended <br />or revoked? If yes check all that apply: <br />❑Denied ❑Suspended ❑Revoked <br />XX <br />4. Is organization exempt from payment of <br />U.S. income tax? If yes, attach copy of <br />letter declaring exemption. <br />XX <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 />2940 Rice Street <br />City, State, Zip <br />Little Canada, Minnesota 55117 <br />County <br />Ramsey <br />Yes <br />XX <br />No <br />1. Are all gambling activities conducted at 1 <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 />XX <br />2. Is site located within city /town limits? <br />XX <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 (if lease or rent) <br />Movers Warehouse, Inc. <br />Address <br />2233 North Hamline Avenue, Suite 220 <br />City, State, Zip <br />Roseville, Minnesota 55113 <br />Gambling Manager Name <br />Joan Kosrnalski <br />Address <br />1115 Beulah Lane <br />�l <br />City, State, Zip <br />St. Paul, Minnesota 55108 <br />The $10,000 fidelity bond required by Minnesota <br />Statutes 349.09 has been obtained. <br />Company Name Bond Number <br />St. Paul Fire & Marine Co. 663NC2798 <br />Name of Organization's <br />a,STANLEY J. LANGE - President <br />Officers and Titles <br />c BARBARA BOELTER - Secretary <br />,Ronald S. Tschida - Executive Director <br />Continued on Page 2 <br />b,Patrick Rooney - 2nd Vice President /Treasurerd <br />CG- 00001 -01 (12/84) <br />7 <br />