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MAP ':In
<br />°"':^•, FOR BOARD USE OwU —_
<br />Charitable Gambling Control Bd
<br />AWav,je}a Rm N-475 Griggs -Midway Bldg
<br />1821 University Avenue
<br />5t. Paul, MN 55104-3383
<br />__�---
<br />GAMBLING LICENSE APPLICATION A'w'
<br />(Class A.B. v a 0
<br />1. ,r• i+��y51fY
<br />INSTRUCTIONS: i. PRINT OR 1VP[,
<br />2. Bring completed appl,catlon to local governing body, obtain .,gnetur• and date on ail Copies,
<br />and leave goldenrod copy. Applicant keeps pink copy and se,.ds remam,r.g cuples to above
<br />address.
<br />e of Application: ---
<br />Class A - fee $100.00 (Bingo, Riffles, Paddlewheels, T,pboards, Pull•Iabs)
<br />Clan e - raw 1 50,00 (Raffles, Paddlewheels, Tipboarde, Pull -Tabs)
<br />Class C - fee 1 50.00 (Bingo only)
<br />Applicant (Official, legal name of organization) Site Address Belrae Ballroom
<br />fhe Assoc'for Alghpimpr's and g
<br />Bw,nen Andrew a : 'goAaaand
<br />W _ ion Disor r ity, State, tip
<br />qhakunpMounds View, Minnesota ..5554
<br />State, lip lrix.ty
<br />lines$
<br />V
<br />,ype o organization
<br />❑ Fraternal O Veterwe
<br />O Rellgioue Other Nonprofit Orgsniratlon
<br />TYPO of OrgWIZbtl n Charter
<br />lnternetlnnal O National State
<br />limit" of YMre ,n wuMier of Articles a/
<br />x1stence (,ri Minnesots) Into rporatlon (If lnaorporati
<br />7503
<br />oeation share Articles are filed
<br />Yes No 1. Does organization have a duce aLr 1 [Uf(
<br />,umber of wctive member!
<br />tia organization been previously llcerw
<br />b the Bosrdr If yea, dive Bate
<br />Ilse lir•nse ever been denied, wspended
<br />X • or revoked? If yea check all that apply:
<br />a. Ia organization exempt from payment of
<br />X U.S. imass tax? If yes, attach copy of
<br />letter declarino even tion.
<br />5, is organization toe exempt frmom Payment
<br />X or Miaaots taxi If yea, otterh Copy of
<br />letter declarinn exempt mn.
<br />Yea I No �. Are sll gambling wtivrtiee cundurted st
<br />LM above Site, If no, Complete a sepa-
<br />rate sPpl,catial fan for each site a a
<br />1 V a
<br />separate license is Issued for a rti it,
<br />X 2, la cite located within City/tan lial to?
<br />7, Does orgeniratlon sun the art# where
<br />gambling sct,vrt�, will Oe tondneted7 I/
<br />X no, attach copy of the ifase for the
<br />Zip
<br />June White
<br />lAwress
<br />7050 MagdaDrive, #210
<br />ity. state, 210
<br />Maple Grove Minnesota 55361
<br />Ttr 1C,000 fidelity bond required by Mimesots
<br />tatutew 349.09 has been obtained.
<br />Compeny News Bind Number
<br />Transamerica Croup #53654640
<br />a. Richard J. Heaney,President C. Claire Seppi, Secretary
<br />b• Joseph R. Welke ice -President d. David J. Westendorf Treasurer
<br />Cr,_IRRM11.01 (1210„ \v q.
<br />1W rMi jM.M • - 2
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