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Charitable Gambling Control. Board <br />Room N-475 Griggs-Midway Bui~dinG.,..t,~ - <br />1821 University Avenue ~.?'- '- <br />St. Paul, Minnesota 55104-3383 . '. ~" ~-' <br />(612) 642-0555 <br /> <br />· GAMBLING LICENSE APPLICATION <br /> <br />INSTRUCTIONS: <br />A. Type or print in ink, <br />B. <br /> <br />Co <br /> <br />FOR BOARD USE ONLY <br /> <br />PAID <br />AMT. <br />CHECK# <br />DATE. <br /> <br />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 a check. <br />Incomplete applications will be returned. <br /> <br />Type of Application: <br />I-IClass A -- Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull-tabs) : <br />~{Class B -- Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull-tabs) I Make checks pa¥able to: I <br />[]Class C -- Fee $ 50.00 (Bingo only) Minnesota Charitable Gambling ControIBoard . <br />[]Class D -- Fee $ 25.00 (Raffles only) .,~. <br /> <br />[]Yes E~No 1. Is this application for a renewal? If yes, give complete license number <br /> <br />~.~Yes [] N o <br /> <br />2. If this is not an application for a renewal, has or~]anization been licensed by the Board before? <br /> license number (middle five digits). I ~ ~ '7. ~"~-'-'~ I :": · <br /> <br />If yes, give base <br /> <br />~es DNo 3. Have Internal Controls been submitted previously? If no, please attach copy. .: <br /> <br />· ~'e s [-INo <br /> <br /> 4. Applicant (Official, legal name of organization) I 5. Business Address of Organization ,,.,. <br /> . I <br /> 6. City, Sta. teyzip , · _ j 7. C,o)Jnty f..;-':: ' .-: 8. Business Phone Number :'~"'; <br /> I <br /> 9..Type of organization: ' ~Fraternal nVeterans r-iReligious ~Other nonprofit*/' . - : - <br />......" *If organization is an "other nonprofit" organization, answer q. uestions 10 through 13. If not, go to question 14. "Other nonprofit" organizations ...-' <br /> · must document its tax-exempt status, t ~.~, - <br /> · <br /> <br />10. IS (~rgani:;ation incorporated as a nonprdfit orgahiza'tion? If-yes; give nbmber aSsign(~l ~o ArtiCles ~r page~nd-;- .;: '\::-*-: <br />.-~"~)'~)knumber: I-'~L''7'- /L~'~-I' Attach copy of certificate. _~)~'~-- .ArT'~/'~:I~ (cc_l <br /> <br />'1~]~es []No 11. Are articles filed with the Secretary of State? . <br /> <br />[]Yes~o 12. Are articles filed with the County? <br /> <br />,~Yes [] No 13. Is organization exempt from Minnesota or Federal income tax? If yes, please attach letter from IRS/or Department of <br /> Revenue declaring exemption or copy of 990or 990T. <br /> <br />· [] Yes.3;~o <br /> <br />15. <br /> <br />17..-Na~ne of Chief Executive Officer <br /> <br /> Title <br /> <br /> C' <br /> <br />19. Name of establishment where gambling will be <br /> <br /> 14. Has license ever been denied, suspended or revoked? If yes, check all that apply: <br /> [] Denie_d. []Suspended E3Revoked Giv~date: { - - <br /> 1 <br />Number of active members 116. Number of years in existence I Note: If less than four years, attach <br /> I <br /> evidence of three years <br /> ~ -- ~ V (~,%- (~.~ ' existence. <br /> 1 8. Name of treasurer or person who accounts for other revenues <br /> <br />21. City, State, Zip <br />CG-0001-02 (8~86) <br /> <br />of the,organization. <br /> <br />Title <br /> <br />Business Phone Number <br /> <br />20. Street address (not nO. Box Number) <br /> <br />22. County (where gambling premises is located) <br /> <br /> c... (c A-.. <br /> <br />White Copy-Board <br /> <br />Canary-Applicant <br /> <br />Pink-Local Governing Body <br /> <br />'{ t <br /> <br /> <br />