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<br /> • , Minnesota Charitable Gambling Control Board FOR BOARD USE ONLY
<br /> -° .."` 900 Summit State Bank Building
<br /> 4 "oat / 310 4th Avenue South
<br /> ,) y Minneapolis, MN 55415
<br /> (612) 341-7676 -
<br /> •
<br /> GAMBLING LICENSE APPLICATION
<br /> (Class A, B, or C) .
<br /> INSTRUCTIONS: 1. PRINT OR TYPE.
<br /> 2. Bring completed application to local governing body, obtain signature and date on all copies,
<br /> and leave goldenrod copy. Applicant keeps pink copy and sends remaining copies to above
<br /> address.
<br /> 3. Changes in application information must be submitted within 10 days after the change.
<br /> Type of Application:
<br /> ❑ Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull-Tabs)
<br /> IDClass B - Eee_$_50.-004Raffles, Paddlewheels, rrpbbards, Pull-Tabs) — -
<br /> ❑ Class C Fee $ 50.00 (Bingo only)
<br /> Make checks payable to: Minnesota Charitable Gambling Control Board.
<br /> Applicant (Official, legal name of organization) 5i$e Addre
<br /> Lake Region ',jockey Association `ovate a's Supper Club, 2400 i i sway ?:
<br /> Business Address Cit , State, Zip
<br /> ?.O. ox 12614 (748 j Snrin.3 Take Road3Uounds ' oundsviewb MN. 5)112 .
<br /> City, State, Zip . vlewf C m
<br /> �: 8Ty ey
<br /> ew Brighton, ,, . ::5112 - of
<br /> K .t8
<br /> County Yes No 1. Are all gambling activities conducted at
<br /> Business Telephone Number Federal I.D. Number the above site? If no, complete a sepa-
<br /> �' " u�lep o54 �� 3 rate application form for each site as a
<br /> (.. ) ZJ^7t..G9 �42J
<br /> separate license is issued for each site. .
<br /> Type of Organization
<br /> (] Paternal Veterans 2. Is site located within city/town limits?
<br /> ❑ Religious Q Other Nonprofit Organization 3. Does organization own the site where
<br /> Type of Organization Charter gambling activity will be conducted? If
<br /> ❑ International 0 National ' 0 State no, attach copy of the lease for the
<br /> Number of Years in Number of Articles of site.
<br /> Existence (in Minnesota) Incorporation (if incorporated) Lessor Name (if lease or rent)
<br /> 13 year5 6
<br /> Location Where Articles are Filed Address
<br /> S :c-jt 177 o:: i't at v
<br /> Yes No 1. Does organization have a dues structure? City, State, Zip
<br /> ' If yes, number of active members
<br /> 2. Has organization been previously licensed Gambling Manager Name
<br /> •
<br /> by the Board? If yes, give date 1.1'=,.:r' ,-)as
<br /> '3. Has license ever been denied, suspended Address
<br /> or revoked? If yes check all thetaPP Y•1 • 1105 ='ike Lane 'CI rc1a
<br /> ❑Denied ❑Suspended ❑Revoked City, State, Zip
<br /> 4. Is organization exempt from payment of ;a Or1 SStnil, .11. .5:;11
<br /> ` U.S. income tax? If yes, attach copy of The $10,000 fidelity bond required by Minnesota
<br /> letter declaring exemption. Statutes 349.09 has been obtained.
<br /> 5. Is organization tax exempt from payment Company Name Bond Number
<br /> of Minnesota tax? If yes, attach copy of
<br /> letter declaring exemption. penri.,
<br /> Name of Organization's Officers and Titles
<br /> C.L_.. i
<br /> ' a. - t -. ,a� ^.rl� c. '.'11'i:i.3S';i t,as, fraasurer
<br /> b.
<br /> d. ^:'a _,urnin , ,::c_ -;
<br /> CG-00001-01 (12/84) Continued on Page 2
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