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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 />,eciv &wk <br />GAMBLING LICENSE &SAWN <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 may be returned. <br />D. Enclose license fee with application. <br />Type of Application: <br />1C(ass A — Fee $ 100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />101Class B — Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -tabs) <br />DClass C — Fee $ 50.00 (Bingo only) <br />DClass D — Fee $ 25.00 (Raffles only) <br />Make checks payable to: <br />Minnesota Charitable Gambling Control Board <br />Check one: 01A. Organization has never been licensed. <br />01B. New site — Give base license number. <br />1 C. Renewal of existing license — Give complete license number. <br />01D. Change in class of an existing license — Give complete license number. <br />D Yes No 2. Has organization ever received a Lawful Gambling Exemption Permit from the Board? <br />permit number <br />� t7 ? 41 <br />If yes, give complete <br />jYes0No <br />4. Applicant (Official legal name of or anization) <br />/ /T 71 ! , ,J.,1 1)4 i!F PP-er. <br />3. Have Internal Controls been submitted previously on a form provided by the Board? If no, please attach copy. <br />5. Business Address of Organization / <br />LAO F- J /rT /_ ( ,a, /iisit/ -<<' <br />City State, Zip 7. County 8. Business Phone Number <br />.� /7-71-.A."-- ,J472,4 MA /At cis-9/7 / f1/�isz- �/ ((/ 2 ) ei -c c/- ,»a. <br />9. Type of organization: ❑Fraternal ❑Veterans ❑Religious gOther nonprofit* <br />.If organization is an. "other nonprofit" organizationranswer questions -10 through12, - If.not,-go to question -13 -"other organizations <br />_must document its tax - exempt status. <br />YYYes0No 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and <br />book number: lc ice," ?d "..Attach copy of certificate. ) r> E <br />JZIYes ONo 11. Are articles filed with the Secretary of'State? <br />pees 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 />0Yes 13. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br />4(/ /t) <br />❑Denied ❑Suspended ORevoked Give date: <br />14. Number of active members <br />3 , / <br />15. Number of years in existence <br />q/ <br />Note: Attach evidence of <br />three years existence. <br />16. Name of Chief Executive Officer (Cannotbe <br />17. <br />Name of treasurer or person who accounts for other revenues <br />Gambling Manager) <br />of the orge ation (Cannot be Gambling Manager) <br />rrAA /K t. f'I C;ZyK <br />(/41/21E-:5' Q1.'?':4,, r: / <br />Title - <br />Title <br />Business Phone Number i "." <br />Business Phone Number <br />(4 1 ) th;(t/ _9772 <br />I (-/ ;) y, -4./-) 72,2 <br />18. Name of establishment where gambling will be <br />r conducte <br />19. <br />Street address (not P.O. Box Number) <br />1 <br />/lrr;E C /4ii/1.47/1 /'7 /j, /An 4/ <br />,- -,29 Yi1 _iC.— gr. <br />200.. City, State, <br />"' <br />21. <br />County (wherre7 gambling is located) <br />/Zip <br />�` �J /�-^ n <br />gill/ <br />/ /'7.77 ! ~- ( /�. /vi /22/l ,5 J /// <br />`preemises <br />l� ./'47511 y <br />CG-0001-0318/88) <br />White Copy -Board <br />Page 3 <br />Canary- Applicant <br />Pink -Local Governing Body <br />