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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 />(612) 642 -0555 <br />GAMBLING LICENSE APPLICATION <br />FOR BOARD USE ONLY <br />License Number <br />AMT <br />PAID <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 />:Class A — Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />LTClass B — Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />OCIass C Fee S 50.00 (Bingo only) <br />OCIass D — Fee $ 25.00 (Raffles only) <br />Make checks payable to; <br />Minnesota Charitable Gambling Control Board <br />❑Yes G■o <br />Yes LON° <br />1. Is this application for a renewal? If yes, give complete license number <br />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/ <br />If yes, give base <br />'(Yes ONo 3. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official,, legal name of organization) <br />, <br />5. Business Address of Organization <br />/ ///7 / / • ( /I.,,., <br />6. /City, State, Zip 7, County'"' 8. Business Phone Number <br />. .. , /4; . `o +',' '• / . / .. /,. ; F' / ((; : 1 r',/ ` t/ - '2 . <br />9. Type of organization: ❑Fraternal DVeterans ❑Religious 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 />tS Yes ONo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />/.. <br />book number: ')% 74-.' "�� '( Attach copy of certificate. <br />QVes ONo 11. Are articles filed with the Secretary of State? <br />S,x1YesONo 12. Are articles filed with the County? <br />93,YesDNo 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 j<i, ' -) r, � %/,•7 <br />DYesEZNo 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />DDenied ❑Suspended DRevoked Give date: <br />15 <br />Number of active members <br />/ <br />16. Number of years in existence <br />/1/ <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. <br />Name of Chief Executive Officer <br />18. <br />Name of treasurer or person who accounts for other revenues <br />_ <br />of the organization. ______, <br />Title <br />Title <br />f''A1 <br />Business Phone Number <br />Business Phone Number <br />19 <br />Name of establishment where gambling will be <br />20. <br />Street address (not P.O. Box Number) <br />conducted , / <br />_ / :�' <br />"l_;._ <br />, 4 <br />%. (:/ <br />21. <br />City, State, Zip <br />22. <br />County (where gambling premises is located) <br />/. <br />CG- 0001 -02 (8/861 <br />White Copy -Board <br />Canary - Applicant <br />PAGE-3 <br />Pink -Local Governing Body <br />