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<br />d< ,,, 'f>A Charitable Gambling Control Board FOR BOARD USE ONLY
<br />•'" 2, Room river ity Avenue
<br />Building ux•m•xvmam
<br />1 , t. P University Avenue
<br />I St. Paul, Minnesota 55104.3383 AMT 16121542-0555
<br />CHECK#
<br />DATE
<br />GAMBLING LICENSE APPLICATION
<br />INSTRUCTIONS:
<br />A. Typeorprintinink.
<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 />A -
<br />Fees 1010.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs)
<br />5
<br />Fees
<br />50.00(Raffles,Paddlewheels, Tipboards, Pull-tobsl
<br />NWxlxckapw•el. r•:
<br />C-
<br />Fees
<br />50.00(Bingo only)
<br />Nalne,suGrltex. p.maanp cemrxea.re
<br />D -
<br />Fees
<br />25.00 (Raffles only)
<br />Ks❑No 1_Is this application for a renewal? If yes, give complete license number 1T1- VJD V l-IIJ / 1
<br />❑Yesf)0o 2. If this is not an application for a renewal has organization benlicensedby the Board before? Ifyes,givebase
<br />9. Type of organization: ❑Fatternal ❑Veterans 111:ligious "Other nonprofit'
<br />-if organization is an"other nonprofit" organization• anew aueslions 10 through 13. if not, go to question 14."Other nonprofit"organiza0•.a
<br />most document its lox -exempt status.
<br />li\Yea a No 10. Is organization incorporated As a nonprofit organization?If yes, give assigned to Articles or peg• and
<br />/ book number: Attach copy of certificate._
<br />ns7 No 11. Are articles filed with the Secretary hate?
<br />❑Yax;"o 12. Are articles filed with the Col ' _
<br />i(Yes' -'a 13. Is organization exempt from Minnesota or Federal income tax ?If yes, please attach letter f•am IRS or Department of
<br />Revenue declaring exemption or copy of 990 or 990T.
<br />^Yasr1(Np 14. Has license ever been denied, suspended or revoked? If yes, check all theta ly:
<br />_ CDenied _❑Suspended f Revoked_ Give date: F_ _
<br />15. Number of active members 16. Number of years in existence Nor.: If less than four years, attach
<br />evidence of three years
<br />r� 31 T existence
<br />17, Name of Chief Executive Officer 118. Name of treasur,i or person who accounts lorotherrevenues
<br />of sho organization.
<br />`% A /.'.
<br />Title .,ge
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<br />Plusmess Phone Nun,bor ,sines Phone Number
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<br />19. Name of establishment where 9ambbnn will be :0 ': uue 'Ibirl .In, 'O Sox Numbed
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