Laserfiche WebLink
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 />iXClass A — Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />LiClass B — Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />LiClass C — Fee S 50.00 (Bingo only) <br />LiClass D — Fee S 25.00 (Raffles only) <br />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />LJYes Ii No 1. Is this application for a renewal? If yes, give complete license number <br />i.RYes (iliNo 2. If this is not an application for a renewal, has organization been licensed by the Board before? <br />license number (middle five digits) B- 01474 -01 1 <br />if yes, give base <br />:Nees l: DNo 3. Have Internal Controls been submitted previously? if no, please attach copy <br />4. Applicant (Official, legal name of organization) <br />Lake Owasso Residence Volunteer Council <br />6. City, State, Zip <br />Shoreview, Minnesota 55126 <br />5. Business Address of Organization <br />210 North Owasso Boulevard <br />7. County <br />Ramsey <br />8. Business Phone Number <br />612 ) 484 -2234 <br />9. Type of organization: ClFraternal L]Veterans LX0ther 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 />r2 Yes F No 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />JAttach copy of certificate. <br />book number: P 545 <br />1.7cYesf7No 11 <br />Are articles filed with the Secretary of State? <br />f; Wes LJNo 12 Are articles filed with the County? <br />unty t. aul -July 27719-77 <br />b Ves!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 />OYes fX No 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 />22 <br />16. Number of years in existence <br />22 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />Janet Thul <br />18. Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Joann Jenkins <br />Title <br />President <br />Title <br />Treasurer <br />Business Phone Number <br />( 612 ) 344 -6147 <br />Business Phone Number <br />1 612 1 641 -6834 <br />19. Name of establishment where gambling will be <br />conducted <br />Little Canada Charitable Bingo Hall <br />20. Street address (not P.O. Box Number) <br />2940 North Rice Street <br />21. City, State, Zip <br />Shoreview, Minnesota 55126 <br />22. County (where gambling premises is located) <br />Ramsey <br />C0-0001- 02(8/86) <br />White Copy -Board <br />Page 8 Canary - Applicant <br />Pink Local Governing Body <br />