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Charitable C.Imbling 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 APPLICATI - ' <br />JUN 10 1987 <br />FOR BOARD USE ONLY <br />License Number <br />PAID <br />AMT <br />CHECK# <br />DATE <br />INSTRUCTIONS: CITY OF <br />A. Type or print in ink. <br />B. Take completed application to local governing body, obtain stgiFiLitE BAb f iA 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 />(EIClass A — Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />OCIass 8 — Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />DClass 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 />EXYes CNo <br />[XYesDNo <br />1. Is this application for a renewal? If yes, give complete license number DO - <br />02069 <br />001 <br />2. If this is not an application for a renewal. has organization been licensed by the Board before? If yes, give base <br />02069 <br />• license number (middle five digits) <br />LYes DNo 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 ceveloc[rentalAchievement Ctr. Inc. 2940 Rice at. <br />6. City, State, Zip • . 7. County 8. Business Phone Number <br />St. Paul, Mn. 55113 • Ramsay (612 ) 484 —man <br />9. Type of organization: ❑Fraternal DVeterans OReiigious acOther 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 DNo • 10. Is organization inccorrgpo�r7atjed as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: ' ""' ' 0U <br />1 Attach copy of certificate. <br />cXXYes CNo 11. Are articles filed with the Secretary of State? <br />DYes LNo 12. Are articles filed with the County? <br />QYes 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 />DYesC4No 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />❑Denied ClSuspended ❑Revoked Give date: - - <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 />1 7. 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 />Business Phone Number <br />(612 ) 736 -5166 <br />19. Name of establishment where gambling will be <br />conducted <br />Little Canada Charity Bingo Hall <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 />CG-0001-0218/86) <br />- White Copy -Board <br />Canary-Applicant <br />PAGE -13 <br />Pink-Local Governing Body <br />