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<br />Charitable Gambling Control Board _
<br />"'� ^ ••• " Room N-475 Griggs -Midway Building FOR BOARD USE ONLY
<br />1821 University Avenue Uan.. flnma„
<br />` St. Paul, Minnesota 55104-3383
<br />f612164(�2 0555 AMT tt' s'c�kJarlA$ Ne ` CHECK# J
<br />DATE' v
<br />�AMBLINGLICENSEAPPLICATIONk:; ' , °r`•�I�AY•kr' it ;'rf�r
<br />� INSiRUCIIONS~j��•'�t"�'-Y,�}!
<br />AType`orprint�ninR
<br />. B "cop completed apphcatmn to local goveming body,'obta!n argne0we and data on all copies, and leave 1 copy Applicant keeps t
<br />rt copy and send songinalto the above address with ' C'�Incomplete ePPBcetinns may be refumed ',r 'thy., Y. i
<br />4,yD7 Enclose license fee with appl¢ction.
<br />•pplicabon,
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<br />r ❑IC R newel ofewsting license Give Iom
<br />-171C: Char P ate license number.. .
<br />ngoinclassofanexison rcens�-"G' - �-�"�'•
<br />iJYes Nor B rve comPletebcense number._
<br />2•Haa organization ever received Lawiul Gambling Exemption Permn from the Board?, if yes, give complete,, ,
<br />jOYwONo ? ;Have/nte- P - i.•:n,er il;f`
<br />melConvols been submitted reviouslyontformprovaiadbytheBoardTlfno pleaseatteehcopy.u.,
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<br />v -.y' •.]gy,-;:• ` .•S r•••••••nN•n¢aUoO/11"a, give number assigne_dto Articlesor pegeaM„i:
<br />book number." W ! Attach copya{cmtlBrate. 3ooK s+[L•i: �YesONo - 1. Are articles tiledwiththSecretaryofStata7 io-.. Pl1GBM�GcI '
<br />;•r.. ❑Yesfi7No 12.,_la orgamzationexempt from Mrnnesw,,or Federal income tex7lfyes,please attach letter from IRS of Department
<br />r 6z':xr+s.Revanue=exemption,:.t, <a, ,.r.
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