Laserfiche WebLink
FOR BOARD USE ONLY <br />Minnesota Charitable Gambling Control Board <br />�:i . j 900 Summit State Bank Building <br />310 4th Avenue South <br />Minneapolis, MN 55415 <br />(612) 341-7676 <br />GAMBLING LICENSE APPLICATION <br />(Class A, B, or C) <br />INSTRUCTIONS: 1. PRINT OR TYPE. <br />2. Bring completed application to local governing body, obtain signature and date on all copies, <br />and leave goldenrod copy. Applicant keeps pink copy and sends remaining cupies to above <br />address. <br />3. Changes in application information must be submitted within 10 days after the change. <br />T e of Application: <br />Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -Tabs) <br />❑ Class B - Fee S 50.00 (Raffles, Paddlewheels, lipboards, Pull -Tabs) <br />❑ Class C - Fee S 50.00 (Bingo only) <br />Make checks payable to: Minnesota Charitable Gambling Control Board. <br />Applicant (rlff+ria), legal name of organization) <br />Business Adr+.ess <br />Cit%. State, Zip <br />County <br />Business Telephone Number <br />Federal I.D. Number <br />Type of Organization <br />❑ Faternal ❑ Veterans <br />❑ Religious ❑ Other Nonprofit Organization <br />Type of Organization Charter <br />International ❑ National ❑ State <br />Number of Years in <br />Number of Articles of <br />Existence (in Minnesota) <br />Incorporation (if incorporated) <br />vocation Where Articles are Filed <br />Yes <br />No <br />1. Does organization have a dues structure? <br />If yes, number of active members <br />. Kos organization been previniisly licensed <br />by the Board' If yes, give date <br />. Has license ever been denied, suspended <br />or revoked? If yes check all that apply: <br />❑ Denied ❑ Suspended ❑ Revoked <br />4. Is organization exempt from payment of <br />U.S. income tax' If yes, attach copy of <br />letter declaring exemption. <br />5. Is organization tax exempt from payment <br />of Minnesota tax' If yes, attach copy of <br />letter declaring exemption. <br />Site Addre w <br />City, State, Zip <br />Count! <br />Yes <br />No <br />1. Are all gambling activities conducted at <br />the above site? If no, complete a sepa- <br />rate application form for each site as a <br />separate licens.. is issued for each site. <br />2. Is site located within city/town limits' <br />3. Does organization own the site where <br />gambling activity will be conducted' If <br />no, attach copy of the !rase for the <br />site. <br />eesor ame (if lease or rent <br />Address <br />City, State, Zip <br />Gambling Manager Name <br />Address <br />City, State, Zip <br />The $10,000 fidelity bond required by Minnesota <br />Statutes 349.09 has been obtained. <br />Company Name Bond Number <br />New of Or anlzation's Officers and Titles <br />a. C. <br />b. d. <br />CG-00001-01 (12/84) Continued on Page 2 <br />