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INSTRUCTIONS: <br />A. <br />8. <br />C. <br />D. <br />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 />Type or print in ink. <br />Take completed application to local governing body, obtain signature and date <br />copy and sends original to the above address with a check. <br />Incomplete applications may be returned. <br />Enclose license fee with application. <br />Type of Application: <br />lass A - Fee S100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />lass B - Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />❑Class C - Fee $ 50.00 (Bingo only) <br />DClass D - Fee $ 25.00 (Raffles only) <br />FOR BOARD USE ONLY <br />License Number <br />PAID <br />AMT <br />.D11TEJa-�" a\ <br />j E\d --U <br />on IY lopiees, andd, gaae 1�copy.:Applicant keeps 1 <br />A\ Gt pan'e - . <br />UdUe <br />i; <br />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />Check one: <br />01A. Organization has never been licensed. <br />01B. New site - Give base license number. <br />01C. Renewal of existing license - Give complete license number. <br />D 10. Change in class of an existing license - Give complete license number. <br />x/878 <br />0/878 <br />❑Yes'No 2. Has organization ever received a Lawful Gambling Exemption Permit from the Board? If yes, give complete <br />permit numbe <br />%Yes <br />ONo 3. Have Internal Controls been submitted previously on a form provided by the Board? If no, please attach copy. <br />4. Applicant (Official, legal name of organization) /� <br />A/c ri %?aatyer Sit! �.,oi & "46 <br />6. City, ,Q / /t7, 5757/7 <br />5. Bys�iness Address of Organization <br />/703/ <br />7. County <br />9. Type of organization: ❑Fraternal ❑Veterans DReligious <br />'If organization is an "other nonprofit" organization, answer questions <br />must document its tax- exempt status. <br />Other nonprofit <br />0 through 12. If not, go to question 13 "Other nonprofit" organizations <br />8. Business Phone Number <br />1 ) <br />/ZoA{ r' <br />Pres DNo 10. Is organization incorporated as a nprofit organization? If yes, give number assigned to Articles or page and <br />Attach copy of certificate. <br />l /53t- <br />book number: <br />XYes O No 11. Are articles filed with the Secretary of State? <br />,(Yes ONo 12. Is organization exempt from Minnesota or Federal income tax? If yes, please attach letter from IRS or Department of <br />Revenue declaring exemption. <br />/f'U; /GZ <br />(YesDNo 13. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />enied DSuspended ORevoked Give date: <br />14. Number of active members <br />/8 <br />15. Number of years in existence <br />// <br />/ <br />Note: Attach evidence of <br />three years existence. <br />16. Name of Chief Executive Officer (Cannot be <br />Gamblin M/anage.r)/... " � � "� <br />%�0A,r7`- (L' (�C/of'lecr <br />17 <br />Name of treasurer or person who accounts for other revenues <br />of the orgy} tion (Cannot be Gambling Manager) <br />(tr /es eGle6er <br />Title <br />re -r/c ` evt.%L' <br />Title <br />reeas4Crer <br />Business Phone Number <br />( ep. ) ox - `f807 <br />Business Phone Number <br />( [2 ..26(- e"71.0.7___ <br />18. <br />Name of establishment where gambling will be <br />conducted C 4ene7rracq -k1n <br />19. <br />Street address (not P.O. Box Number) <br />,!' 8/'74 A/er7ij t etc e St� e <br />20. <br />City, State, Zip /� <br />4:7Y7: C z cfc(ci /V, CS /7 <br />21. <br />County (wh ambling premises is located) <br />ae‘>sey <br />CG 0001 - 0318/88) <br />White Copy -Board <br />PAGE- 1 - <br />Canary-Applicant <br />Pink -Local Governing Body <br />