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Charitable Gambling Control Board <br />Room N -475 Griggs- Midway Building <br />1 821 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 />❑Class A — Fee $ 100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />%Class B — Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />❑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 />❑Yes XNo 1. Is this application for a renewal? If yes, give complete license number <br />3idYes ONo 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 />01425 <br />If yes, give base <br />%Yes ON° 3. Have Internal Controls been submitted previously? If no, please attach copy. <br />4. Applicant (Official, legal name of or ani ation) <br />Nc Yr; GC <br />5. Business Addjess of Organization <br />a1i4 I13cIIWOcc) <br />6. City, State, Zip 1r� 7. ounty <br />2 �/ <br />oscv:Il< frt∎Af. S S I13 aw.S* (611 ) 633 -oIS6 <br />9. Type of organization: DFraternal ❑Veterans ❑Religious li4 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 />8, Business Phone Number <br />6 YesONo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: L43 P„/, aD 6 Attach copy of certificate. <br />tg,'Yes0No 11. Are articles filed with the Secretary of State? <br />(*Yes ON° 12. Are articles filed with the County? <br />ZYes 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 />°Yes"6No 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 />1 <br />16 Number of years in existence <br />of 6 <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />17. Name of Chief Executive Officer <br />i t, <br />R. 120L -"y VA Arc O YI <br />18. <br />Name of treasurer or person who accounts for other revenues <br />of the organization. <br />O- tc mA' --r- ller—. <br />Title <br />t`cc c. wt ✓c. 1�(- ccTo.— <br />Title <br />'Tr t-,e c. r' <br />Business Phone Number <br />(6)1)633 -oi56 <br />Business Phone Number <br />(611) aqb -0,S =2 <br />19. Name of establishment where gambling will be <br />conducted <br />1�c tAcsyc1sLrc2tk r _a r <br />20. <br />Street address not P0. .BBox Number) <br />Soy 1,..), 1c-e f <br />21. City, State, Zip <br />L,tfi. Ca„3.1 MIA- s 5/13 <br />22. <br />County (where gambling premises is located) <br />R2 c(cLi <br />CG-0001-0218/86) <br />White Copy-Board <br />Page 82 <br />Canary - Applicant <br />Pink -Local Governing Body <br />