Agenda - Council - 05/14/1991 - Laserfiche WebLink

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FOR BOARD USE ONLY LG2OOA Rev. (10/12/90) Minne.~ta Lawful Gambling Organization License Application - Part I Legal Name of Organization I Other names used Business Address of Organization - Street or P. 0 Box (Do not use address of gambling manager) [ Business ID Number(Sales &Tax Permit) I I State 7ip Code_ Count,/ Name of chiet executive officer Last First Middle Maiden Date of bir~ Address of chief executive officer - Street or P. O. Box Business phone number Business phone number State Zip Code County I I I I I I I I I I I I Name of treasurer or person responsible for organization's other revenues TitJe / Date of birth Business phone number Type of Nonprofit Organization: [] Fraternal [] Veterans ID Religious '~il~'Other nonprofit Number of years organization has been in existence as · nonprofil organization ~-<.~Dur~'~.~-~ Attach a copy of a cerlificate of good standing as a nonprofit organization from the Minnesota Secretary of State's office and/or a letter h'om the IRS dectadng income ax exemption. (Do not send a sales tax permit or Federal employer identification information) Number of Active Members 'CiZ'=~..L, (must be age 18 and older) When does the organization hold regular meetings? Day (s) [ 5T ~, '~ ~ (jjF_.z_.~/,,j~...~urs *-~ .~0~,~,~, Has the Compensation Schedule for the current year been submitted on the form provided by the board?/~ yes [] If no, attach a copy Have Internal Controls for the current year been submitted on the form provided by the board? .~' yes [] If no, attach a copy, ~i ??~~~~::~::~::~::~::~::~::~::~::~::~::::~::~:::.~::~::::::[~::~:::::::~::~::~::~:~::~::::::~::~[[~::::::[~:.~::~::~:.:.~::~::~::~::~[~::::::::::~::::~::~[~::~[ iii::ii i ii:::: :::: ::i::i:: i!:: ::..., .: .... . :: ... ..... ::;:; ::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::: ::::::::: :::::: ::::: .............................................................. :::::::::::::::::::::::::::::::::::::::::::::::::::: ::'.:::::: Class of Organization License [] Class A-- Bingo, Raffles, Paddlewheels, Tipboards, Pull-tabs ~ Class B m Raffles, Paddlewheeis, Tipboards, Pull-tabs [] Class C-- Bingo only [] Class D-- Raffles only ~Check the box that most accurately summarizes the g-mbUng at all of your premises. The organization license must reflect all forms of g. mbllng conducted by your organization. [] Organization has never been licensed. '~ Renewal of existing license -- Fill in (;gmDlete license number ~ 1 [] Chance in clas~ of existing license-- Fill in comolete license number [] Previously expired license -- Fill in comolete license number