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Charitable Gambling Control Board <br />Room N -475 Griggs- Midway Building <br />1821 University Avenue <br />St. Paul, Minnesota 551043383 <br />(612) 642 -0555 <br />GAMBLING LICENSE APPLICATION <br />INSTRUCTIONS: <br />A. Type or print inink. <br />B. Take completed application to local governing body, obtain <br />copy and sends original to the above address with a check. <br />C. Incomplete applications will be returned. <br />FOR BOARD USE ONLY <br />License Number <br />PAID <br />DATE <br />53t <br />CITY OF <br />LITTLE CANADA <br />ignature and date on all copies, and leave 1 copy. Applicant keeps 1 <br />Type of Application: <br />K]Class A — Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />LJCIass B — Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull-tabs) <br />❑Class C — Fee S 50.00 (Bingo only) <br />❑Class D — Fee S 25.00 (Raffles only) <br />MinnMinnesota payable to: <br />Minnesota Charitablo Gambling Control Board <br />CYes ONo 1. Is this application for a renewal? If yes, give col iplete license number Lai 01489 - L006 <br />MIYesL]No 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) [ 01489 <br />JYesON° 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 />4orammummay Humane Societyof Ramsey Count4VW4NNORRIttaNW 1115 Beulah Lane <br />St.CPaul, Mn. 55108 <br />7. County 8. Business Phone Number <br />Ramsey ( 612 ) 645 —PETS <br />9. Type of organization: OFraternal DVeterans ❑Religious N10thernonprofit* <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 />Y,iYes DNo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number. 681 —NPA J Attach copy of certificate. <br />{.Yes LJNo 11. Are articles filed with the Secretary of State? <br />)(Yes ENo 12. Are articles filed with the County? <br />KlYes ONo 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 />XYesl No 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />❑Denied ❑Suspended ❑Revoked Give date: - — - J <br />15. Number of active members <br />481 <br />16. Number of years in existence <br />115 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />Ron Tschida <br />18. <br />Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Patrick Rooney <br />Title <br />2nd Vice President /Treasurer <br />Title <br />Executive Director <br />Business Phone Number <br />( 612 1 645 —PET'S <br />will be <br />Hall <br />20. <br />Business Phone Number <br />( 612 I 370 -7096 <br />Street address (not P.O. Box Number) <br />2940 Rice St. <br />19. Name of establishment where gambling <br />conducted <br />Little Canada Charity Bingo <br />21. City, State, Zip <br />Little Canada, Mn. 55113 <br />22. <br />County (where gambling premises is located) <br />Ramsey <br />CG- 0001 -02 18/86) <br />White Copy -Board <br />Canary - Applicant <br />Page 17 <br />Pink -Local Governing Body <br />