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Charitable Gambling Control Board <br />Room N -475 Griggs- Midway Building <br />C• 1 821 University Avenue <br />z St. Paul, Minnesota 55104 -3383 <br />16121642-0555 <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 />CXClass A - Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />CCIass B - Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />❑Class C - Fee $ 50.00 (Bingo only) <br />GClass D -- Fee S 25.00 (Raffles only) <br />X.:Yes L:No 1. Is tliis'applica eifior a "f•enewal? Ilf yes, give complete license number' L A - 00465 .11005 1 <br />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />C'.Yes:. :No 2. If this is not an application for a renewal, has organization been licensed by the Board before? If yes, give base <br />license number (middle five digits) J <br />%'Yes :jNo 3. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official, legal name of organizarinnl <br />St. Joseph's Society for Charity, Inc. <br />6. City, State, Zip 7. County <br />St. Paul, MN 55117 Ramsey <br />5. Business Address of Organization <br />132 Demont Avenue E. ¥[341 <br />8. Business Phone Number <br />(612 ) 484 -2659 <br />9. Type of organization: LiFraterna( GVeterans x:Religious 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 />XThiesE2No 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: 396302 _ 1 Attach copy of certificate. <br />Xi Vert I: No 11. Are articles filed with the Secretary of State? <br />x'Yes CINo 12. Are articles filed with the County? <br />Xi Yes TT 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 />❑YesX:No 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />CDenied ESuspended DRevoked Give date: - - <br />15. Number of active members <br />27 <br />16. Number of years in existence <br />35 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />Patricia Pillsbury <br />18 Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Laura Mitchell <br />Title <br />Chief Executive Officer <br />Title <br />Treasurer <br />Business Phone Number <br />(612 ) 429 -6295 <br />Business Phone Number <br />(612 ) 484 -1684 <br />19. Name of establishment where gambling will be <br />conducted <br />Little Canada Bingo tall <br />20. Street address (not P.O. Box Number) <br />2940 Rice Street <br />21. City, State, Zip <br />Little C.nada, MN 55117 <br />22. County (where gambling premises is located) <br />Ramsey <br />CG -0001 -02 (8/86) <br />White Copy -Board Page 10 Canary - Applicant <br />Pink-Local Governing Body <br />