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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 />%aeons. N VTOM <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 />CCIass A — Fee $ 100.00 (Bingo, Raffles, Paddlewheels, Tlpboards, Pull•tabs) <br />,$Class B — Fee $ 60.00 (Rattles, Paddlewheels, Tipboards, Pull-tabs) <br />CCIass C — Fee $ 50.00 (Bingo only) <br />❑Class 0 — Fee $ 25.00 (Raffles only) <br />1 <br />Matta °necks Payable ta: <br />Mlnnaaota Charitable Gambino Control Bowl <br />1 <br />CYeegtlo 1, Is this application for a renewal) If yes, give complete license number I <br />YasONo 2. If this is not an application for a renewal, has organization been licensed by the Board before? <br />license number (middle five digits) 1 C o2 / % K <br />$Yes ONo <br />f_J <br />If yes, give base <br />3. Have Internal Controls been submitted previously? If no, please attach copy <br />4. Ap pllicant (Official, legal ame of oroization) <br />ire (4de L,gtie CP'� 1c 1tsic. <br />6. Cii1t'w. State, Zip 7, C_ <br />Noari, SrG'At,L Mk) i 537 aLint <br />5. Business Addreas of Organization <br />2 /0 -7' e C. <br />9. Type of organization: C=raternal °Veterans °Religious ' ther nonprofit' <br />"It organization d an "other nonprofit" organization, answer questions 0 through 13, If not, go to question 14. "Other nonprofit" organizations <br />must document its taxroxemot status. <br />A YIYesONo 10. Is organization incorporated as 4---i Attach organization? If yes, give number assigned to Articles or page and <br />/ ` book number: 560 't W5'2 1 Attach copy of certificate. <br />`$ <br />Yes ONo 11. Are articles filed with the Secretary of State? <br />Yes ONo 12, Are articles filed with the County? <br />?<YesDNo 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 No 14. Has license ever been denied, suspended or revoked? If yes. check all that apply: <br />I I <br />8. Business Phone Number <br />(GIP. )777 -352a <br />°Denied CSusoended <br />°Revoked <br />Give date' <br />15. Number of active members <br />18 <br />17. Name of Chief Executive Officer <br />c)e F —gas <br />Note: If leas than four years, attach <br />evidence of three years <br />existence. <br />18. Name of treasurer or person who accounts for other revenues <br />of the prgann. � <br />/ 125 tt.,er T r" 4Set• <br />Title <br />qes, ' u.Qd Or <br />Business Phone Number <br />Titles <br />#/2] Mt,v /C l'407'0R, <br />( 1912) 971— 357a) <br />Business Phone Number <br />I a.) 777 —_75-2 2 <br />19. Name of establishment where gambling will be <br />conducted .--7\ <br />�ICK4-MM -RY s <br />20. Street address (not P.O. Box Number) <br />35'/1 //deSv, <br />21, Gay, State, Zip <br />L i ri G•e 0411)14 el ad. SS /lp <br />22. County iwnere gambling premises is located) <br />ICH&A set <br />C3.0001.02 (9.'(45) - White Copy•Board <br />Canar•Appecarit Plnk•Locsl GGoverning Sody <br />Page 17 <br />