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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 />JR BOARb jjyl: 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 retn{li1Ihg copies to above
<br />address.
<br />3. Chan.es in application information must be submitted within 10
<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 />LFO.JS Gl J.4 QF < n-7-4C C0-1411-f
<br />Business Address
<br />/ix?) (\ 0X / -7 011
<br />•
<br />City, State, Zip
<br />5r. PAW- Mid nliitrA
<br />County /
<br />Business Telephone Number Federal I.D. Number
<br />((e(2) (91\ -xi bI q f - /Ja, 29-7 79e
<br />Type of Organization
<br />WFaternal ❑ Veterans
<br />❑ Religious PXOther Nonprofit Organization
<br />Type of Organization Charter
<br />ja International ❑ National ❑ State,
<br />Number of Years in .
<br />Existence (in Minnesota)
<br />Number of Articles of
<br />Incorporation (if incorporated)
<br />1}4A1J9c4 r
<br />Location Where Articles are Filed
<br />Yes
<br />No
<br />1. Does organization
<br />If yes, number
<br />have a dues structure? y
<br />of active members
<br />\,
<br />2. Has organization
<br />by the Board?
<br />been previously licensed
<br />date
<br />If yes, give
<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 />ZgJdf e
<br />Site Address e
<br />the than
<br />City, State, Zip
<br />Lirr�4 C'i1+�%,�,, 551/7
<br />County
<br />Ain45£
<br />Yes
<br />1. Are all gambling
<br />the above site?
<br />rate appiica4,lnn
<br />separate lickr,s
<br />activities conducted at
<br />if no, complete a sepa-
<br />turm for each site as a
<br />+,as issued for each site.
<br />2. Is site locat.ad within city /town limits?
<br />3. Does organizetiuh own the site where
<br />gambling activity will be conducted? If
<br />no, attach ccpy or
<br />site.
<br />essor ame 1 ease or ran', ""
<br />P7 V.Ci (,OA -gf
<br />Address
<br />3 Nfl
<br />City, State, Zip
<br />"Se 729/44„5-3" //3
<br />the lease for the
<br />?YLL 4C So in' 112-2-c
<br />Gambling Manager Nate
<br />Tester! A. S,1ehp,
<br />Address
<br />City, State, Zip
<br />/MAC viEu1 b A
<br />The $10,000 fidelity bond ter:iilted by Minnesota
<br />Statutes 349.09 has been cv,4nN.,i,
<br />Bond Number
<br />37F maxi? /Lit
<br />Name of Organ.izat
<br />on's
<br />(ija,nc)
<br />C.14p 57-0/06
<br />55
<br />Company Name
<br />4c7/1/i1 0/4$/Jnt -T r
<br />Officers and Titles
<br />• kC MftlYt t gird c.
<br />• RILL toff- Pc✓lbnrs er (mot c.e. Pees
<br />CG- 00001 -01 (12/04)
<br />c Roc e. r4 (nib t t' e f
<br />d. (°-, Nti(�e
<br />O
<br />y
<br />g:
<br />tootinued on Page 2
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