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ri <br />.:o�.THE�Sja <br />02 <br />Charitable Gambling Control Board <br />Room N -475 Griggs- Midway Building <br />1821 University Avenue <br />St. Paul, Minnesota 55104 -3383 <br />(612) 642 -0555 <br />GAMBLING LICENSE APPLICATION <br />FOR BOARD USE ONLY <br />License Number <br />PAID <br />AMT <br />CHECK# <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 />❑Class 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 />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />Cx1Yes ONo 1. Is this application fora renewal?( If yes,rgive complete license number:# $ - _01484 <br />DYes DNo 2. If this is not an application for a renewal, has organization been licensed by the Board before? <br />license number (middle five digits) <br />If yes, give base <br />Gd Yes ONo • 3. Have Internal Controls been submitted previously? If no, please attach copy <br />4. Applicant (Official, legal name of organization) <br />Jacobsen Memorial Auxiliary #487 <br />5. Business Address of Organization <br />423 Eli Road <br />6. City, State, Zip <br />Little Canada, MN 55117 <br />7. County <br />Ramsey <br />8. Business Phone Number <br />1612 1 484 -2234 <br />9. Type of organization: LFraternal b Veterans DReligious DOther 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 />❑Yes RNo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: Attach copy of certificate. <br />DYes Ix'No 11. Are articles filed with the Secretary of State? <br />RlYesk)No 12. Are articles filed with the County? <br />Yes DNo 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 />DYes)tiNo 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />❑Denied ❑Suspended ❑Revoked Give date: <br />15. Number of active members <br />52 <br />16. Number of years in existence <br />26 years <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />Mrs. Dorothy Heppner <br />18. Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Rose Bruch, <br />Title <br />President of Auxiliary <br />Title <br />Treasurer <br />Business Phone Number <br />( 612 1 484 -7365 <br />Business Phone Number <br />1 612 ) 484 -8026 <br />19. Name of establishment where gambling will be <br />conducted <br />Dick & Mary's Bar <br />20. Street address not P.O. Box Number) <br />3356 N. Rice Street <br />21. City, State, Zip <br />Little Canada, MN 55117 <br />22. County (where gambling premises is located) <br />Ramsey <br />CG- 0001 -02 (8/86) <br />White Copy -Board <br />Page 20 <br />Canary - Applicant <br />Pink -Local Governing Body <br />