Laserfiche WebLink
INSTRUCTIONS: <br />A. Type or print in ink. MAY 6 1981 <br />6. 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. CITY OF <br />C. Incomplete applications will be returned. LITTLE CANADA <br />Type of Application: <br />(.Class A — Fee $ 100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />OCIass B — Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />❑Class C — Fee $ 50.00 (Bingo only) <br />['Class D -- Fee $ 25.00 (Raffles only) <br />Yes r INo 1. Is this application for a renewal? If yes, give complete license number I. j - L c 3- 931 - It. -1c <br />❑Yes (73No 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) <br />4;YesLINo 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 />s i 1�<1k1rt of / '�(e „ ;� t c;1 r�1 .�� i c. c°. Sy -T�Li) . <br />6. City, State, Zi f 7. County 8. Business Phone Number <br />(Ai 4'1 r f,I r:1 .5%7i: 3 <br />1 <br />r'> � _ ) 4 " `11 ' <br />9. Type of organization: ❑Fraternal LlVeterans ❑Religious I Other 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 />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 />GAMBLING LICENSE APPLICATION <br />FOR BOARD USE ONLY <br />license Number <br />PAID <br />AMT <br />CHECK II <br />1 <br />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />iXYes!.'No 10. Is organization incorporated as a� nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: r1L `S.5' 1 Attach copy of certificate. •)c) cj e. ' <br />ly!Yes' ..1No 11. Are articles filed with the Secretary of State? <br />1-- Yes I.1No 12. Are articles filed with the County? <br />I ;Yes[7No 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 />L]Yes []No 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />C;Denied EllSuspended r Revoked Give date. <br />15 Number of active members 16. Number of years in existence Note: If less than four years, attach <br />G.v evidence of three years <br />existence. <br />17 Name of Chief Executive Officer <br />e Ir <br />Title <br />Business Phone Number <br />18. Name of treasurer or person who accounts for other revenues <br />of the organization. + --- ! 1 <br />.. <br />i 1;1 1 r *ICIS'J` `. <br />Title <br />t U cf- <br />Business Phone Number <br />19. Name of establishment where gambling will be <br />conducted J <br />21. City, State, Zip <br />20. Street address (not P.O. Box Number) <br />Ict •:`i r`j it ` , c.. L. <br />22. County (where gambling premises is located) <br />Ti - ( �_ .C, i (i ;.t .. , _. , L1 r ` l • t l t 1 f l <br />CG-0001-0218/86) White Copy-Board Canary - Applicant <br />Page 5 <br />Pink-Local Governing Body <br />