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I <br />I 9OD Summi! State Bank Building <br />~' 310 ~th Avenue South <br />~. ~y MJnneapoJis, MN 55~1~ <br />I (612) 3~1-7676 <br /> <br /> I., <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />IFOR <br /> <br />BDARD USE DNLI' <br /> <br />GAMBLING LICENSE APPLICATION <br /> (O~s & B, or 0 <br /> <br /> ]NSIRUCllDN5: ]. PR1NI OR 1YPE, <br /> 2. Bring completed application to local governing body, obtain signature and date on al! copie <br /> and leave goldenrod copy. Applicant keeps pink copy and sends remaining copies to above <br /> address. <br /> }, ~anqe, s in application information must be submitted ~ithjn 20 deys e~ler ~ cheque, . <br />[l~e or A~lJcatJon: <br /> Class A - Fee $~OD.~ (emgo, Raffles, Paddl~eele, li~oatds, Pull-l~s) <br /> C]ess B - fee $ 50.~ (Raffias, Paddle.eels, lipboatds~ Pull-l~s) <br /> Class C - Fee $ 50.00 (Bingo only) <br /> ~ke ~hecks psyab)e to: Ninnesota ~titeble 0~blinq C~trol Board. <br /> <br />A~plicant (Official, legal name of organization) <br />i~usiness Address <br />City, S~a[e, ~ip <br />C~nt'y <br />B~ines~' lelepho~e N~nber1 F~e~el ].'D. N~e~ <br />,( ) <br /> 1~ of O~ganization <br /> ~ feterna~ D Veterans <br /> T~ of Organization <br /> D International 0 ~t~nel ~ State <br /> N~er of Y~s in ~er of Articles of <br /> E~ate~e (~ Mi~esota) :]~orporation (if i~ot~Teted)[ <br /> <br /> ~es No . ~s organization have e dues structure? <br /> If ~es, ~er of active ~mbers. .. <br /> ~. ~ organi~za[~on be~ previously Jicensed <br /> by [~ ~ard? If yes, g~ve date <br /> 5~ ~s )~Cense ever been denied, ~spended <br /> or tev~ed? If yes c~ck al) [~[ apply: <br /> D~ied O~spended GRey.ed <br /> a. Is organization ex.pt <br /> U.S. <br /> )et[er ~c)arJn9 exemption. <br /> 5. ]s organization tax exempt fr~ paint <br /> of M~nesota tax? ]f yes, attach e~y of <br /> )ette~ ~clatin~ exemption. <br /> <br />Site Address <br /> <br />City, State, Zip <br /> <br />County <br /> <br /> Yes ~ No ~. Are ail gambling activities conducted , <br /> [ / the above site? Ir no, complete a aep~ <br /> ! [ rate application form For each site as <br /> J J ~e~ara~e,license is issued for.each <br /> <br />J il. Is site located within city/to~n limib <br />[ ti. Does organization own the site ,':re <br />[ [ gambling activity ~ill be conducted? <br />I [ no, attach copy of the lease for the <br />I , ,,! site. - <br />Lessor Name (if lease or tent) <br /> <br />Address <br /> <br />City, State, Zip <br /> <br />Rddress <br /> <br />City, State, Zip <br /> <br />Ire $10,000 fiOelity bond required by Minnesota <br />Statutes ~49.09 has been obtained. <br /> Company Name Bond Nt~ber <br /> <br />Name of Organization's Officers and litles <br /> <br />f~-O0001-Ol (12/84) Continued on Page 2 <br /> <br /> <br />