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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 />(6121642-0555 f' <br />• <br />GAMBLING LICENSE APPLICATLI " 1987 <br />INSTRUCTIONS: CITY O1- <br />A. Type or print in ink. 'UT LE CANADA, <br />B. Take completed application to local governing body, obtain signature and date on all copies, and leave 1 copy. Applicant keeps 1 <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 />AMT - - - --- - - -- - - -- <br />CHECKn <br />Type of Application: <br />XCIass A — Fee $ 100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />CJCIass B -- Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) Make checks payable to: <br />L1CIass C -- Fee $ 50.00 (Bingo only) Minnesota Charitable Gambling Control Board <br />❑Class D — Fee S 25.00 (Raffles only) ��ll <br />IXYes ❑No 1. Is this application for a renewal? If yes, give complete license number �-_A_) - 02069 H . L 00 1 <br />IXYes UNo 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) L V 206 9 _ 1 <br />1 <br />L4Yes ❑No 3'. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official, legal name of organization) North 5. Business Address of Organization <br />Suburban Developmental Achievement Ctr. Inc. 2940 Rice St, <br />6. City, State, Zip 7. County 8. Business Phone Nurnber <br />St. Paul, Mn. 55113 Ramsey L612 ) 484_7000 <br />9. Type of organization: ❑Fraternal OVeterans OReligious XOthernonprofit* <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 />C[Yes CNo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number 4670 Attach copy of certificate. <br />IXYes EiNo 11. Are articles filed with the Secretary of State? <br />C?Yes IN.No 12. Are articles filed with the County? <br />IXYes ❑No 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 (XNo 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />[-Monied ESuspended ORevoked Give date: C <br />15. Number of active members <br />43 <br />16. Number of years in existence <br />26 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />Phillip C. Saari <br />18. Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Steven Beilke <br />Title <br />Executive Director <br />Title <br />Treasurer, Board of Directors <br />Business Phone Number <br />( 612 ) 484 -7000 <br />will be ._e..� <br />Hall <br />Business Phone Number <br />(612 ) 736 -5166 <br />19. Name of establishment where gambling <br />conducted <br />Little Canada Charity Bingo <br />20. Street address not P.O. Box Number) <br />2940 Rice St. <br />21. City, State, Zip <br />Little Canada, Mn. 55113 <br />22. County (where gambling premises is located) <br />Ramsey <br />C8- 0001 -02 (81861 <br />White Copy-Board <br />Canary Applicant <br />Page 26 <br />Pink•Local Governing Body <br />