Laserfiche WebLink
LG220 <br />Rev06/95 <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 />OrganjYation Name <br />Previous lawful gambling exemption number <br />Strc i / S� , ty� / /i if. <br />. .• //3 Code <br />�/??/�12y <br />Name of Chief Executive Officer <br />First Name <br />of organization (CEO) <br />Las Name <br />Daytime Phone number ofC0 <br />/ , <br />Name of Organization Treasurer <br />First Name <br />Last e <br />Daytime Phone Number of Treasurer <br />,! jl / e <br />Type of Nonprofit Organization <br />Check the box below which best describes <br />your organization <br />Fraternal <br />Veterans <br />Religious <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />(—j IRS letter indicating income tax exempt status <br />DCertificate 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 />fS‘Other nonprofit <br />Gambling Premises Information <br />Name of Establis ment where gam ling activity will be conducted <br />Street City State Zip Code Co ty <br />Date(s) of activity (for raffles, indicate t e date of the drawing) / <br />____,/4— 91, V - — Y7 <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br />Bingo rAcRaffles 0 Paddlewheels 0 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 />For Board Use Only <br />Date & Initials of Specialist <br />/ / <br />Pane 2 <br />