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Charitable Gambling Control Board <br />Room N -475 Griggs - Midway Building <br />1 821 University Avenue <br />St. Paul, Minnesota 55104 -3383 <br />16121642-0555 <br />GAMBLING LICENSE APPLICATION <br />FOR BOARD USE ONLY <br />License Number <br />PAID <br />AMT <br />CHECK1 <br />DATE._ -_. <br />INSTRUCTIONS: <br />A. Type or print in ink. <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 />Type of Application: <br />5 Class A — Fee $ 100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />OCIass B — Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />DClass C — Fee $ 50.00 (Bingo only) <br />❑Class D — Fee $ 25.00 (Raffles only) <br />f <br />Make chocks payable to: <br />Minnesota Charitable Gambling Control Board <br />NYesDNo 1. Is this application for a renewal? If yes, give complete license number L± J - L 02070 <br />1 -LDDi J <br />❑Yes ❑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) J <br />NYes ❑No 3. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official, legal name of organization) Minnesota 5. Business Address of Organization <br />Registry of Interpreters for the Deaf _atffi#h P.O. Box 4414 <br />6. City, State, Zip 7. County <br />St. Paul, MN 55104 Ramsey <br />8. Business Phone Number <br />( ) None <br />9. Type of organization: °Fraternal LlVeterans ❑Religious xi0ther nonprofit* <br />*If organization is an "other nonprofit" organization, answer questions 10 through 13. If not, go to question 14. <br />must document its tax - exempt status. <br />"Other nonprofit" organizations <br />to Articles or page and <br />50'esFIN° 10. Is organization incorporated -as a nonprofit organization? If yes, give number assigned <br />book number: Y — 359 J Attach copy of certificate. <br />Ix_ Yes 1No 11. Are articles filed with the Secretary of State? <br />[ &Yes L1No 12. Are articles filed with the County? <br />CCYes LINo 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 />E1Yes[%CNo 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />- - I <br />❑Denied ❑Suspended DRevoked Give date: <br />15. <br />Number of active members <br />237 <br />16. Number of years in existence <br />16 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. <br />Name of Chief Executive Officer <br />Rubin Latz <br />18. <br />Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Louise Hayden Falk <br />Title <br />President <br />Title <br />Treasurer' <br />19. <br />Business Phone Number <br />( 612 ) 296 -9386 <br />Name of establishment where gambling will be <br />conducted <br />Little Canada Charity Bingo Hall <br />20. <br />Business Phone Number <br />( 612 ) 545 -0134 <br />Street address (not P.O. Box Number) <br />2940 Rice St. <br />21. <br />City, State, Zip <br />Little Canada, MN 55113 <br />22. <br />County (where gambling premises is located) <br />Ramsey <br />CG- 0001 -02 181861 <br />White Copy -Board <br />Canary - Applicant <br />Page 30 <br />Pink -Local Governing Body <br />