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' I ~~ Minnesota CharitabJe GambJJn[ ControJ Board <br /> 900 Summit State Bank Bu[Jdin[ <br /> I ~ 310 ~th Avenue South <br /> MinneapoJis, MN <br /> (612) 3~ 1-7676 <br /> <br />IINSTRUCT IONS ~ 1. PRINT DR TYPE. <br /> 2, <br /> <br />GAMBLING LICENSE APPLICATION <br /> (Cia.ss A, B, or O <br /> <br />Type of Application: <br />~'] Class A - Fee $100.00 (Bingo, Rarflem, Pmddlewheelm, Tipboards, Pull-Tabm) <br />~ Clams a - Fee $ 50.00 (Rmfflem, Paddlewhesls, ltpboerde, Pull-Tabs) <br />[] Class C - Fee $ 50.00 (Bingo only) <br />Make checks payable to= Minnesota L'haritmble Gamblinq ~o~trol Bomrd. <br /> <br />FOR BOARD USE ONLY <br /> <br />Bring completed application to local governing body, obtain signature and date on all copies, <br />end leave goldenrod copy. Applicant keeps pink copy end sends remainin9 copies to stove <br />address. <br />~hsnqe~ in apDi~a[ion information mus~ b~ submitted within I0 da¥~ a~ter the chanoe, <br /> <br />The Super Bowl <br /> <br />Site A~dre~e <br />6720 138~h Ave. N~ <br />Cit~, State, Zip <br />~amsey, Minn. 55303 <br />County <br />inoka <br /> <br /> Yes No 1. Ate all gambling activities conducted at <br /> the above site? If no, complete a sepa- <br /> X rate application form for each site as a <br /> separate license is issued for each site. <br /> ~ 2. Is site located within city/town limits? <br /> ~.Ooes organization o~n the site where <br /> X gamblin9 activity ~ill be conducted? <br /> no, attach copy or the lease for the <br /> site. <br />Lessor Name ~f lease or rent) <br />AOdress <br />6720 138~h Ave. <br />City, State, Zip <br />Ram$~v~ ~inn. 55303 <br />~amoling Manager Name <br />RoBert Holm <br />~ddresa <br />2344 Nicollet Ave. S. #150 <br />~ity, State, Zip <br />Minneapolis MM '5~N4 <br />The $10,OOO f~delity ~ond required by Minnesota <br />Statutes ~.09 has been obtained. <br />Company Name Bond Number <br />~e~eTal [=s. 80351275-~ <br /> <br />Applicant (~fficial, legal name o¢ organization) <br />_Cystic Fibrosis Foun. dation, MN ChapteT <br />Business Address <br />2344 Nicollet Ave. S., #150 <br />City, State, Zip <br />Minnea¢olis, MN [$404 <br />County <br />Hennepin <br />Business Telephone 'Number1 Federal I.D. Number <br />612 ) 871-0462 ] 4100877670 <br />Type of Organization <br />~ Faternal C~ Veterans <br />~ Religious~ O~her Nonprofit Organizat. ion <br />~ype of Otganizati'on Charter <br />~ International [] National ~ State <br />NLmoer of Years ~n 4umber of Articles of <br />Existence (in Miraqesota) Incorporation (i? incorporatedY, <br />30 0495310 <br />Location I~ere Articles are Filed <br />De la-are <br /> Yes No 1. Does orQanLzatipn have a.dues struc, tur. e? <br /> VolunE~e S ~ ~OUU <br /> X It' yes, numoer or ac~zve members <br /> 2. Has organization been previously licensed= <br /> X by the Board? I? yes, ~ive date~-~ <br /> ~. Has license ever been denied, suspended <br /> X <br /> or revoked? If yes check all [hat apply: <br /> ~3Denied 0Suspended r~Eevoked <br /> 6. Is organization exempt t'tom payment <br /> U.S. income tax? If yes, attach copy <br /> letter declarin~ exemption. <br /> 5. Is organization tax exempt t'ro~ payment <br /> of Minnesota tax? If yes, attach copy of <br /> letter declarin~ exemption. <br /> <br />IIa-Sue Morrison, <br />IIh-Warren Malkerson. <br /> <br /> Name of Orqsnization's Officers and Titles <br /> <br />Vice -President <br /> <br />C~00001-01 (12/~M) <br /> <br />Morthp Coventry ~ Secretary <br /> <br />Bob MmlBM: Treasurer . <br /> <br /> Continued on Page 2 <br /> <br /> <br />