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INSTRUCTIONS: <br />A. Type or print in ink. qj mil " N '' <br />B. Take completed application to local governing body, obtain si n5F'tire and date on all copies, and leave 1 copy. Applicant keeps 1 <br />4 Pt 9 9 Y 9 P PY� PP P <br />copy and sends original to the above address with a check. <br />C. Incomplete applications will be returned. <br />Charitable Gambling Control Board <br />Room N -475 Griggs- Midway Building <br />1821 University Avenue <br />St. Paul, Minnesota 55104 -3383 <br />(61 2) 642 -0555 <br />FOR BOARD USE ONLY <br />GAMBLING LICENSE APPLICATION <br />`Liconso Numbar <br />PAID <br />AMT <br />CHECK# <br />Type of Application: <br />LXClass 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 />CJCIass D — Fee $ 25.00 (Raffles only) <br />Make chocks payable to: <br />Minnesota Charitable Gambling Control Board <br />IX YesCDNo 1. Is this application for a renewal? If yes, give complete license number A - L 0187$ - L002 J <br />DYes ONo 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) I u 187W <br />N'Yes ❑No 3. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official, legal name of organization) <br />North Ramsey 500th Lions Club <br />6. City, State, Zip <br />St. Paul, Mn. 55117 <br />5. Business Address of Organization <br />2.0. Box 17031 <br />7. County <br />Ramsey <br />8. Business Phone Number <br />1612 ) 636 -7990 <br />9. Type of organization: ❑Fraternal ❑Veterans OReligious CXOther nonprofit* <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 />Wes CiNo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: H47, B.162 j Attach copy of certificate. <br />CXYes ❑No 11. Are articles filed with the Secretary of State? <br />C2*Yes 0No 12. Are articles filed with the County? <br />LLYes CJNo 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 />❑Yes [No 14. Has license ever been denied, suspended or revoked? If yes, check all that applly: <br />ElDenied GSuspended CiRevoked Give date: J <br />15. Number of active members <br />20 <br />16. Number of years in existence <br />10 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />J.L. Suggs Jr. <br />18. <br />Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Charles Weber <br />Title <br />President <br />Title <br />Treasurer <br />Business Phone Number <br />( 612 ) 426 -4236 <br />19. Name of establishment where gambling will be <br />conducted <br />Little Canada Charity Bingo Hall <br />20. <br />Business Phone Number <br />( 612 ) 484 -7832 <br />Street address (not P.O. Box Number) <br />2940 Rice St. <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 (6/86) <br />White Copy -Board Page 21 Canary - Applicant <br />Pink -Local Governing Body <br />