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Minnesota Charitable Gambling Control Board rOR BOARD USE ONLY <br />900 Summit State Bank Building <br />310 4th Avenue South <br />Minneapolis, MN 55413 <br />(612) 341-7676 <br />GAMBLING LICENSE APPLICATION <br />(Class A, B, or C) <br />INSTRUCTIONS: 1. PRINT OR TYPC. <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 copies to Wove <br />address. <br />3. Ciumgr, in application information m t be submitted within <br />Type or Application: <br />❑ Close A - fee 1100.00 (Bingo, Raffles, Paddlewheel,, Tipboarda, Pull -tabs) <br />E) Class B - ree S 50.00 (Raffles, Paddlewheels, Tipboards, Pull -Tabs) <br />❑ Class C - TOO S 50.00 (Bingo Only) <br />MWe chocks YWle to: Minnesota Charitable Gambling control Board. <br />Applian! (Offletal, legal fuse of organization) <br />Nat'l. MS 8oclety, MN North Star Chapter <br />Business Addna. <br />2344 Nicollet Avenue <br />City, State, Zip <br />Minneapolis, WH 55404 <br />Canty <br />Hennepin <br />Bufinama Telephone umse <br />federal I.D. Number <br />(612 ) 870-1500 <br />41-079_065a <br />ype Of Organization <br />❑ faternal Cl VWerana <br />❑ Religious U other Nonprofit Organization <br />Type of Organization Charter <br />International Q National ❑ State <br />Nwoer of Yusrs in <br />Mmaer of Articles of <br />Evistenca (in Minnesota) <br />Incorporation (if incerpontee) <br />31 years <br />19 <br />Location Mrre Articles an riled <br />New York <br />Yee <br />No <br />1. Does organization have a dues structure? <br />X <br />If yes, or of active members 33,000 <br />. Has Organization been previously licensed <br />X <br />the Bomrd? If 22, live date <br />. Ilan llceme ever bean denied, suspended <br />ravokad7 If yea ehac4 .11 that apply: <br />X <br />❑ar <br />Oniad ❑Susosndad ❑Revoked <br />A. Is Orgnizatin exempt free payment of <br />X <br />U.S. income tax? If yes, attach copy of <br />letter doclarim ea tin. <br />. Ie pegr+izatin tax esmapt from psyrnt <br />X <br />of Mbaeusta taxi If ya, attach copy of <br />letter employing exemption. <br />Site A <br />City, 5zi t e3 <br />County <br />02Q LYf/ <br />Yee <br />No <br />. An dl go.CL setivitiea eon tad et <br />the abovz site. If no, complete a sepa- <br />rate application foal for each site as a <br />X <br />separate license is issued for each site. <br />It. Is site located within city/tors, limits? <br />one organizatics, own the site where <br />13. <br />gambling activity will be conduct.d7 If <br />X <br />no, attach copy of the lease for the <br />site. <br />aseaClyme (t ens or rand <br />Address <br />City, State, Zip <br />O <br />k'CNd <br />emb zng Meager Name <br />Willard M. Munger, J <br />Address <br />2344 Nicollet Avenue <br />lty, state, zip <br />Minneapolis, MN SS404 <br />The 110,000 fidelity bond required by Minnesota <br />tatutes 349.09 has bean obtained. <br />Cager:y Noms Bond rusher <br />Fidelity i Depositors 9682268 <br />rlar of Or nization's Officers bed Title* <br />a• Bin $lay Nuarphy Jr. Chair <br />c• J•CEre J. Wood, Treasurer <br />"old Friada V <br />d. Joanne TAvin. Secret," <br />