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Charitable Gambling Control Board <br />Room N -475 Griggs - Midway Building <br />1821 University Avenue <br />St. Paul, Minnesota 55104 -3383 <br />(612) 642 -0555 <br />GAMBLING LICENSE APPLICATION <br />FOR BOARD USE ONLY <br />License Number <br />PAID <br />AMT <br />r 'CHclglgt <br />INSTRUCTIONS: <br />A. Type or print in ink. hJ` '71- <br />B. Take completed application to local governing body, obtain signature anfhdpteo)a. Ip o i s„ and leave 1 copy. Applicant keeps 1 <br />copy and sends original to the above address with a check. t ` flPr� <br />C. Incomplete applications will be returned. <br />Ttype of Application: <br />Class A — Fee $ 100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />DClass 8 — Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />DClass C — Fee $ 50.00 (Bingo only) <br />DClass D — Fee $ 25.00 (Raffles only) <br />Make chocks payable to: <br />Minnesota Charitable Gambling Control Board <br />XCJYes CINo 1. Is this application for a renewal? If yes, give complete license number L A ] - 00465 1_ 005 J <br />CDYes CJNo 2. If this is not an application for a renewal, has organization been licensed by the Board before? If yes, give base <br />license number (middle five digits) r <br />I]Yes CONo 3. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official, legal name of organization) 5. Business Address of Organization <br />ST. JOSEPH'S SOCIETY FOR CHARITY, INC. 132 Demont Avenue East #341 <br />6. City, State, Zip See Attadhed�ert irate) 7. County 8. Business Phone Number <br />St. Paul, MN 551.17 Ramsey_ ( 612 ) 484 -2659 <br />9. Type of organization: ClFraternal DVeterans XJReligious DOthernonprofit` <br />"If organization is an "other nonprofit" organization, answer questions 10 through 13. If not, go to question 14. "Other nonprofit" organizations <br />must document its tax - exempt status. <br />X.3Yes DNo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: r 396302 i Attach copy of certificate. <br />N_TjYes [ 7No 11 Are articles filed with the Secretary of State? <br />rxYes ON() 12. Are articles filed with the County? <br />IXYes i7No 13. Is organization exempt from Minnesota or Federal income tax? If yes, please attach letter from IRS or Department of <br />Revenue declaring exemption or copy of 990 or 990T. <br />EJYes £No 14. Has license ever been denied, suspended or revoked? If yes, check all tha�y: <br />E]Denied DSuspended DRevoked Givedate• - <br />15. Number of active members <br />27 <br />16. Number of years in existence <br />35 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Narne of Chief Executive Officer <br />Patricia Pillsbury <br />18. <br />Name of treasurer or person who accounts for other revenues <br />of the organization. Laura Mitchell <br />Title <br />)hief Executive Officer <br />Title <br />Treasurer <br />Business Phone Number <br />( 612 )429 -6295 <br />19. Name of establishment where gambling will be <br />conducted <br />,ittle Canada Bingo Hall <br />20. <br />Business Phone Number <br />( 612 ) 484 -1684 <br />Street address (not P.O. Box Number) <br />2940 Rice Street <br />21. City, State, Zip <br />,ittle Canada, MN 55117 <br />22. <br />County (where gambling premises is located) <br />Ramsey <br />CG- 0001 -02 18/86) <br />White Copy -Board sage 14 Canary- Applicant <br />Pink -Local Governing Body <br />