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Charitable Gambling Control Board <br />Room N-475 Griggs-Midway Building <br />1821 University Avenue <br />St. Paul, Minnesota 55104-3383 <br />(612) 642-0555 <br /> <br />GAMBLING LICENSE APPLICATION <br /> <br /> FOR BOARD USE ONLY <br />License Number <br /> <br />PAID <br />AMT. <br />CHECK# <br />DATE <br /> <br />INSTRUCTIONS: <br />A. Type or print in ink. <br />B. Take completed application to local governing body, obtain signature and date on all copies, and leave 1 copy. Applicant keeps 1 <br /> copy and sends original to the above address with e check. <br />C. incomplete applications may be returned. <br />D. Enclose license fee with application. <br /> <br />Type of Application: <br />~Class A -- Fee $100.00 (Bingo, Rsffles, Po,,d,ewhee s, Tipboards, Pu,,-~o~S~ <br />E3Class B -- Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull-tabs) <br />[]Class C -- Fee $ 50.00 (Bingo only) <br />I-IClass D -- Fee $ 25.00 (Raffles only) <br /> <br />Make checks payable to: i <br />Minnesota Charitable Gambling Contro~ Board <br /> ! <br /> <br />Check one: <br /> <br />[]lA. Organization has never been licensed. <br /> <br />[]lB, New site -- Give base license number. <br /> <br />[] 1C. Renewal of existing license -- Give complete license number. <br /> <br />[] 1D. Change in class of an existing license -- Give complete license number. <br /> <br />I L:-ooss? I <br /> <br />i-lYes F~No 2. Has organization ever received a Lawful Gambling Exemption Permit from the Board? If yes, give complete <br /> permit number [ I <br /> <br />E}Yes []No 3. Have Internal Controls been submitted previously on a form provided by the Board? If no, please attach copy. <br />4. Applicant (Official, legal name of organization) 5. Business Address of Organization <br />Cyat~C FJbrcs~s Foundation L30 0~I,', 6rOv~ SL, it~ ~-!(; <br />6, City, State, Zip [ 7. County 18. Business Phone Number <br /> <br />9. Type of organization: []Fraternal rlVeterans []Religious ~Othernonprofit* <br /> 'If organization is an "other nonprofit" organization, answer questions 10 through 12. If not, go to question 13. "Other nonprofit" organizations <br /> must document its tax-exempt status. <br /> <br />[~Yes ~No 10. Is organization incorporated as e n.onprofit organization? If yes, give number assigned to Articles or page and <br /> book number: l 0/~ Q ~ ~ ~ ('~ I Attach copy of certificate. <br /> <br />[~Yes ~No 11. Are articles filed with the Secretary of State? <br />[~Yes [] No 12. Is organization exempt from Minnesota or Federal income tax? If yes, please attach letter from IRS or Department of <br /> Revenue declaring exemption. - <br /> <br />i~Yes []No 13. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br /> <br /> []Denied ~Suspended ~Revoked Give date: I ] <br /> <br />14. Number of active members J 15. Number of years in existence Note: <br /> <br />Attach evidence of <br />three years existence. <br /> <br />16. <br /> <br />Name of Chief Executive Officer (Cannot be <br />Gambling Manager) <br /> <br /> Title <br /> <br />.--xacu" Jr6 DJrec"or <br /> <br />17. <br /> <br />Name of treasurer or person who accounts for other revenues <br />of the organization (Cannot be Gambling Manager) <br /> <br />Title <br /> <br />Business Phone Number <br /> <br />Business Phone Number <br /> <br />(..-.~o ) ~- ;:./_ _,¢ ~ ! ", <br /> <br />18. <br /> <br />Name of establishment where gambling will be <br />conducted <br /> <br />20. City, State, Zip <br /> <br />19. Stree[ address (not P.O. Box Number) <br /> ~ I ~" :.~. W V ~ '" <br /> <br />21. County (where gambling premises is located) <br /> <br />CG-0001-03 (8/88) <br /> <br />White Copy-Board <br /> <br /> Canary-Applicant <br /> <br />Page 1 of 2 <br /> <br />Pink-Local Governing Body <br /> <br /> <br />