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Charitable Gambling Control Board
<br />Room N-475 Griggs-Midway Building
<br />1821 University Avenue :
<br />St. Paul, Minnesota 55104-3383
<br />(612) 642-0555 ·
<br />
<br />GAMBLING LICENSE APPLICATION
<br />
<br /> FOR BOARD USE ONLY
<br />ILicense Number
<br />
<br />PAID
<br />AMT.
<br />CHECK#
<br />DATE.
<br />
<br />INSTRUCTIONS:
<br />A. Type or print in ink.
<br />B. 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 />C. Incomplete applications will be returned.
<br />
<br />Type of Application:
<br />'J~Class A -- Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull-tabs)
<br />~)Class B -- Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull-tabs)
<br />[~ClassC-- Fees 50.00 (Bingo only)
<br />[~Class D -- Fee $ 25.00 (Raffles only)
<br />
<br />Make checks payable to:
<br />Minnesota Charitable Gambling Control Board
<br />
<br />I~Yes~No 1. Is this application for a renewal? Ifyes, give complete license number ~ - l
<br />
<br />.~,,Yes []No 2. If this is not an application for a renewal, has organization been licensed by the Board before? If yes, give base
<br /> license number (middle five digits) I /'~. ( '7 ~- -'~ I
<br />
<br />~[~Yes D No 3. Have Internal Controls been submitted previously? If no, please attach copy.
<br />4.f,Applicant'(Official' legal name of organization).~ ~ 17isIBusiness Address of Organization___.
<br />6. Cgunty
<br />
<br />City, State,~Zip 18. Business Phone Number
<br />
<br />Type of organization: I-IFraternal r-lveterans l-lReligious ,~,Other nonprofit' {
<br />° If organization is an "other nonprofit" organization, answer questions 10 through 13. If not, go to question 14. "Other nonprofit" organizations
<br />must document its tax-exempt status.
<br />
<br />~Yes E~No 10. Is organization incorporatedTas a nonprofit organization? If yes, give number assigned to Articles or page and
<br /> book number: Ic~ ': '? ' ~,-/~ Attach copy of certificate.
<br />
<br />~Yes [~No 11. Are articles filed with the Secretary of State?
<br />· ~&Yes ~ No 12. Are articles filed with the County?
<br />,~¥es [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 990 or 990T.
<br />
<br />~Yes ~No 14. Has license ever been denied, suspended or revoked? If yes, check all that apply:
<br /> ~Denied ~,Suspended [~Revoked Give date: I -
<br /> /
<br />
<br /> 15. Number of active members t 16.
<br />" I / "-'"~' I
<br />1 7. Name of Chief Executive Officer "
<br />', r r - ~ .... ~ "7'"'~
<br />
<br />19.
<br />
<br />Title
<br />
<br />Business Phone Number
<br />
<br /> ./- i ~, ~ t '"'~
<br />(,,,, ~,; ) -~ '2/_ .,> ~,~ ~ '
<br />
<br />Name of establishment where gambling will be
<br />conducted
<br /> x f/ f "'//''
<br />
<br />Number of years in existence I Note: If less than four years, attach
<br /> evidence of three years
<br /> .~_ existence.
<br />
<br /> 18. Name of treasurer or person who accounts for other revenues
<br /> of the organization.
<br /> i' C ;: &.). d-'
<br />
<br />21. City, State, Zip
<br />;'";/-:7/I ,C.' t' . ,~ ... ,. , , -. :. :,.' ~ ..' I',. ,.
<br />
<br />Title
<br />
<br />Business Phone Number
<br />
<br />2_0. Street address (not PO. Box Number)
<br /> >-/I >{4: L.c.: / (..: '"'-:-'"
<br />
<br />22. County (where gamblin~ premises is located)
<br />
<br />CG-O001-02 (8/86)
<br />
<br />White Copy-Board
<br />
<br />Canary-Applicant
<br />
<br />Pink-Local Governing Body
<br />
<br />
<br />
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