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<br />dM� Minnesota Charitable Gambbng Control Board roe BOARD USE ONLY
<br />6 M 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 0
<br />INSTRUCTIONS: .. PRINT OR TYPE.
<br />S. Bring completed application to local governing body, obtain signature and onto on ail copbe,
<br />and leave gildenrod caps. Applicant keeps Dirk rapf and sends remaining copies to above
<br />address.
<br />1. f*t.A in as 1 cation information mat ba a,te,tted elth,n 10 data •/t!I tie cdl�._ _ _
<br />rT or Apllcationi
<br />U Close A - nee S100Ap (Bingo, Raffles, Paddleweels, T,pbnarda, Pull -Tab!)
<br />IClass B - fee S 50.00 (Raffles, Pesdlamrele, Tipboards, Pull-Tmbm)
<br />class C - fee S SC.00 (Bingo only)
<br />. ww%,ur.n1. to nuavaata rnantabla Laeblina retrol Board.
<br />Applicant (Official, legal name of Organization)
<br />Unitldll E AU I Flom
<br />Bwi)esa Addreem
<br />P. 0. WX 657, Ilat TriCk Avu,us
<br />City, state, tip
<br />tvalLth, :Ltrtrrnota 55734
<br />County
<br />St. mails
<br />Business Telepnone Numbs federal I.D. Number
<br />file ) 744-5167 23-70,24370
<br />yps of OrgailratiM
<br />d] Paternal ❑ yeterane
<br />Rel lg,ow 6,Other N roflt Organization
<br />Type of Organization Charter
<br />Internet, oriel 0 40tlonal ID state
<br />Asmbrr 0 Vasa in
<br />IU,m► r of Articles of
<br />Existence kin Nlrrieats)
<br />Incorporation, (if Incorporated)
<br />u,
<br />tI-r,
<br />_
<br />Location Mere Art,rleo are filed
<br />S4cwtiery at Stew
<br />Yes
<br />Me
<br />I. Does argwiratlon MN a dues structure?
<br />If yes, number of active members
<br />. Has organization bean previously licensed
<br />the Bard'' I/ raw. give data
<br />New Iseems over been denied, appended
<br />or revoked' If yes check all that apply,
<br />)(
<br />nDauad C)Sua ended ❑R vakad
<br />a, is organization exempt from payment of
<br />U.5. income to., 1f yea, attach copy of
<br />ietter declarl 0-9010tion,
<br />. Is orWI:dtlon tav uopt free psyment
<br />of "imamate tw If y, attach copy of
<br />x
<br />Lietter
<br />declarinj exed0ttOn.
<br />a. D. wally rageiell, IRutid,ant
<br />b. Julin Iltwooin, Zoe I'nmai unt
<br />Ct40D001-01 (12/84)
<br />$its Address
<br />':ul 1r9 . 1C
<br />City, State, lip
<br />;411 Cbmty . xai I'? Ibtuasvisv MH 55112
<br />County
<br />,Igaff
<br />yes
<br />No
<br />. Am all gobl,ng activities conducted wit
<br />tie oboes Site' If roc Complete a Mpo-
<br />X
<br />rate application form for own uts es a
<br />Separate license is issued I
<br />•�
<br />2. Is site located within city/too, limit.
<br />1. Des organization don the site Sham
<br />gambling activity will be caducted' If
<br />no. attach copy of tie lamas for the
<br />eSo esa Or fan
<br />Uljtxnla Inc.
<br />Address
<br />'41) Cauntb fiml' :.2
<br />ity, State, tip
<br />•nerth.vic.r, I'!�tna+ota 55112
<br />ling Flonagar Name 7/0-5167
<br />lb r A. Cu.iin
<br />ese
<br />,'. 0. N)K
<br />ty, State, Zip
<br />,v eioth, %, n sUtd 55734
<br />fidelity bond ropared by Nineeats
<br />letutes 149.09 ire been obtained.
<br />Company Now Bond gmbar
<br />lmstia I'in On. r,11117671
<br />Stanley D. lAi#IiL'ti, 'Laretarr '
<br />Jdin n*ntovtet., t..nlr.r
<br />Continued on Poo 2
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