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'"' "'" ~-"~ Charitable Gambling C~mtrol Board <br /> " ' :*'~- Room N~475 Griggs-M~dway Buildino <br /> ' : .:., 1821 University Avenue <br /> ', '- ' '~":.': t? St, Paul, Minnesota 55104-3383" <br />~ (612) 642-0555 <br /> <br />GAMBt lNG LICENSE.;/DPLICATION <br /> <br />INSTRUCTIONS: <br /> <br />FORBOARDUSEONLY <br /> <br />-..V.?AMT <br /> -::CHECK# <br /> DATE <br /> <br />Ac <br /> <br /> copy end sends or;g[nal to the above addres,~ with e check. <br />C. Incomplete applications will be returned. <br /> <br />Type of Application: <br />(lass A -- <br />lass B <br />LOClass C - <br />{~]Cless D -- <br />~es~No <br />E] Yes 1::3 No <br /> <br />Type or print in ink. <br />Take completed application to local Duvernlng body, obtain signature and date on all copies, and leave 1 copy. Applicant keeps <br /> <br />~e; ~No <br /> <br />Fee $100.00 (.?,Jngo, Raffles, Pedciewheels, Tipboards, FhJll-tabs) <br />Fee $ 5000 (Raffles, Paddlewhe~ is, 3ipboarde, Puli-tabs) <br />Fee $ 5000 (8ingo only) <br />Fee $ 25 00 (Raffles only) <br /> <br /> 'i <br />1. Is this ~pplication for a r~newal? if yes, give complete license number ~-J-~ - J 2 0 / ~o <br />2. If this is no~ an applic[~tion for a renewal, has organization been licensed by the Board before? <br /> ficense nun,be, (middle five digits) E ~f'~~ I <br />:3. Have Int.Fr,ai Controls bean submitted previously? If no. please attach copy. <br /> <br />to: I <br /> <br />If yes, give base <br /> <br /> Business Address of Organization <br />4~,~ Applicant (Of/ici,l, legal narrator org~nizatior~) 5. . <br /> <br />6. City, State, Zip 7. ~unW ~Js. ~ine~ ~one Numb~ <br /> <br /> Type of organization: [:]Fraternal EJVete~ans ~Religious ~'Other nonprofit" <br /> elf ~gan~ati~ ~ an "othe, nonprofit" organiz <br /> must d~ument its t;lx:~x,~t status. . <br />~Yes ~No 10. Is organiz etlon incorporated <br /> book nu,r,ber: ~-'~t~r';Z_~ A~ach copy Of ce~ificate. <br /> <br />~r~fes [~No 11. Are a~ticles filed with the .Sec, eta~y of State? <br />~e~ ~No 12. Are article, s filed with the COL Flty'? <br /> <br />[~Yes [~ No <br /> <br />13. <br /> <br />Is orflani~ orion exempt from E~innesota or Federal ~ncome t, ax? If yes, please attach letter from 1RS or Department of <br />Reve~ue declaring exemption ol copy of 990 or 990T. <br /> <br />14. Has license ever been denied, suspended or revoked? If yea, check all that apply:. <br /> l~Denied ~]Suspended [~Revoked Give date: J - <br /> <br />15. <br /> <br />Number of ective members 16. Nun ber ~f years in existence <br /> /.)(~ <br /> <br />17. Name/Ofg~ef Executive Officer <br /> Title <br /> <br />18. <br /> <br /> ..... ]Note: lf less than four years, attach · <br /> <br /> ' I evidence of three years <br /> - existence. <br /> <br />Name of treasurer or person who accounts for other revenues <br /> <br /> Business Phone Numb~.r <br /> <br />19. Name of establishment where gambiing wiii be <br /> conducted . <br /> <br />21. CiW, State. Zip <br /> <br />_ .... <br />CG~I ~2 {~B6) / <br /> <br /> of the o~a~zetio, n. <br /> .. <br /> Business P~one Number <br /> <br /> ( <br />20. Street address (not P.O. Box Numar) <br /> <br />22. County (where gambling premises is located) . -. <br /> <br />Cnnsry-Appllc~nt <br /> <br /> <br />