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LG220 <br />Rev06f96 <br />Minnesota Lawful Gambling <br />Application for Authorization for an <br />Exemption from Lawful Gambling License <br />For Board Use Only <br />Fee Paid <br />Check # <br />Initals <br />Date Recd <br />Organization Information <br />Or. =`�zation Name h� d/ /�i � �� <br />i <br />Previous lawful gambling exemption number <br />StreetF ,,,/ / City Sate Zip Code 76,C;unty <br />Name of Chief Executive Officer <br />First Name <br />of org =ni tion (CEO) <br />Last Na e <br />Daytime Phone number of CEO <br />Name of Organization Treasu <br />First Na� <br />er <br />last e <br />Daytime Phone Number of Treasurer <br />‘5/ fi� t3 <br />Type of Nonprofit Organization <br />Check the box below which best describes <br />your organization <br />Fraternal <br />Veterans <br />Religious <br />i Other nonprofit <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />NM IRS letter indicating income tax gxempt status <br />[]Certificate of good standing from the Minnesota Secretary <br />of State's office <br />QA charter showing you're an affiliate of a parent <br />nonprofit organization <br />proof previously submitted and on file with the Gambling Control <br />Board <br />Gambling Premises Information <br />Name f Establis ment where <br />mbling activity will be cond cted ix./ <br />Street / n City D State Zip Code County (j <br />°� C!/L2 --o_.-- 70 <br />Date( of activity (for raffles, indicate the date of the drawing) <br />Check the box or boxes h indicate the type of gambling activity your organization will be conducting <br />Bingo Raffles Paddlewheels Pull -tabs Tipboards <br />Be sure the Local Unit of Government and the CEO of your organization sign <br />the reverse side of this application. <br />Page 19 <br />For Board Use Only <br />Date & Initials of Specialist <br />/ <br />