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.791 E fir <br />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 APPLICATId'r <br />INSTRUCTIONS: <br />A. Type or print in ink. <br />B. Take completed application to local governing body, obtain sig}L TthtEdi ASrdte oA 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 />JUN 10 1987 <br />CITY OF <br />FOR BOARD USE ONLY <br />License Number <br />PAID <br />AMT <br />1;111 CHECKI <br />DATE <br />Type of Application: <br />O1 Class A — Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />.00iass 8 — Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />GClass C — Fee S 50.00 (Bingo only) <br />GClass D — Fee S 25.00 (Raffles only) <br />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />LXYes CNo 1. Is this application for a renewal? If yes, give complete license number 111. - <br />CXYes CNo 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 />02069 <br />001 <br />02069 <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) North <br />Suburban ISuburban DevelormentalAchievement Ctr. Inc. 2940 Rice $t. <br />6. City, State, Zip • . 7. County <br />St. Paul, Mn. 55113 ' <br />5. Business Address of Organization <br />8. Business•Phone Number <br />Ramsey (612 ) 484 -7000 <br />9. Type of organization: ❑Fraternal OVeterans ❑Religious N Other nonprofit' <br />•If organization is an "other nonprofit" organization, answer questions 10 through 13.11 not, go to question 14. "Other nonprofit" organizations <br />must document its tax - exempt status. <br />CRYes CNo • 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: 196/700 Attach copy of certificate. <br />R'iYes CNo 11. Are articles filed with the Secretary of State? <br />CYes [No 12. Are articles filed with the County? <br />G4Yes ONo 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 />CYes CNo 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />❑Denied C}Suspended ❑Revoked Give date: <br />15 Number of active members <br />43 <br />16. Number of years in existence <br />. <br />26 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />Phillip C. Saari <br />18. <br />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. <br />Street address (not P.O. Box Number) <br />• <br />2940 Rice St. • <br />21. City, State, Zip <br />Little Canada, Mn. 55113 <br />22. <br />County (where gambling premises is located) <br />Ramsey <br />CG- 0001.02 (8/86) <br />• White Copy -Board <br />Canary - Applicant <br />Pink .Local Governing Body <br />