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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 />PAID <br />AMT <br />CHECK# <br />DATE <br />INSTRUCTIONS: <br />A. Type or print in ink. <br />8. 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 $ 100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />CiClass B -.. Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />Li Class C —. Fee $ 50.00 (Bingo only) <br />❑Class D — Fee $ 25.00 (Raffles only) <br />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />gYesfiNo 1. Is this application for a renewal? If yes, give complete license number 51-1 1 - <br />❑Yes l )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) <br />XYesDNo 3. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official, legal name of organization) 5. Business Address of Organization <br />Se.ruav)Ts of Mummy 4-11c a41 Y 01 R;C- t- 5S* 11i /5a <br />6. City, State „Zip 7. County 8. Business Phone Number <br />5i. KZ uk fri PI PI 5%/_3 Rcirvl5c..! (a) /Z )ij 3- 9 /cR E <br />9. Type of organization: DFraternal iVeterans C,Religious % 0ther 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 />00393 <br />)(Yes ❑No 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: <br />Attach copy of certificate. <br />Yes LJNo 11 . Are articles filed with the Secretary of State?' <br />pVes ❑No 12 Are articles filed with the County? <br />$Yes I. N0 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 INo 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />p_c_LJ ell 6,00k v-S3 <br />7-24 /o /eJ <br />❑Denied ❑Suspended ORevoked Give date: ,.J- -d6 - 87 <br />15 Number of active members <br />C2� <br />16. Number of years� in existence <br />6 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17 Name of Chief Executive Officer <br />Cefesfc Youie <br />18. <br />Name of treasurer or person who accounts for other revenues <br />of the organization. <br />Sfonley Bale/ <br />Title <br />C ie. f 5 wee . Cif, c-e1- <br />Title <br />4cc°6 u01 67 11 -t- <br />Business Phone Number <br />( /.�z) i.3g- c_ 32/ <br />Business Phone Number <br />(C /0 5d -qG /‘., <br />19. Name of establishment where gambling will be <br />conducted /_ /Pi // <br />% / //t �r� /ri i/c./6/ r <br />20. <br />Street address (not P.O. Box Number) <br />9�� �/ c e S -l. <br />21. City, State, Zip <br />L /ll Ca q n 0 c c7 i /\ 1 / 3--:—// <br />7 <br />22. <br />County (where gambling premises is located) <br />/1 6-,147 s e y <br />CG- 0001 -02 18/861 <br />White Copy -Board <br />Page 12 Canary - Applicant <br />Pink -Local Governing Body <br />