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Minnesota Charitable Gambling Control Board FOR BOARD USE ONLY <br />a, 900 Summit State Bank Building <br />_ < , 310 4th Avenue South <br />Minneapolis, MN 55415 <br />(612) 341-7676 <br />GAMBLING LICENSE APPLICATION <br />(Class A, B, or Q <br />INSTRUCTIONSr 1. PRINT OR TYPE. <br />2. Bring completed application to local governing body, obtain signature and date on all copies, <br />end leave goldenrod copy, Applicant keeps pink copy and sends remaining copies to above <br />address. <br />Type of Application; <br />❑ Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -Tabs) <br />❑ Close B - Fee S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -Tabs) <br />❑ Class C - Fee S 50.00 (Bingo only) <br />Applicant (Official, legal name of organization) <br />Business Adiress <br />City, State, Zip <br />County <br />Business Telephone Number <br />) <br />Federal I.D. Number <br />ype of Organization <br />❑ Feternal ❑ Veterans <br />❑ Religious ❑ 0ther Nonprofit Organization <br />Type of Organization Charter <br />❑ International ❑ National [] State <br />Number of Years in INumber <br />of Articles of <br />Existence (in Minnesota) <br />Incorporation (if incorporated) <br />Location Warp Articles are Filed <br />Yes <br />No <br />1. Does organization have a dues structure? <br />If yes, number of active members <br />. Has organization been previcuoly licensed <br />by the Bard? If yu, iva date <br />. Has license ever been denled, suspended <br />or revoked? If yes chock all that epplyr <br />❑Denied [Suspended ❑Revoked <br />4. Is organization exempt from payment of <br />U.S. income tax? If yes, attach copy of <br />letter declaring exemption. <br />5. Is organization tax mxemot from payment <br />of Minnesota tax? If yea, attach copy of <br />letter declaring exemption. <br />Site Address <br />City, State, Zip <br />Canty <br />Yes <br />No <br />1. Are all gambling activities conducted at <br />the above site? If no, complete a sepa- <br />rate application form for each site as e <br />separate license is issued for each site. <br />2. Is site located within city/town limits? <br />3. Does organization own the site where <br />gambling activity will be conducted? If <br />no, attach copy of the lease for tho <br />sate. <br />essor Name i east or rent) <br />Address <br />City, State, Zip <br />5ambling Manager Nam <br />Address <br />City, State, Zip <br />The $10,000 fidelity bond required by Minnesota <br />Statutes 349.09 has been obtained. <br />Company Name Bond Number <br />Name of Or anlzation's <br />Officers and Titles <br />c. <br />b. <br />d. <br />CO-00001-01 (12/84) Continued on Page 2 <br />