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Rev066 Minnesota Lawful(G � bil 99$ <br />Application for Authori atiojotsii, ING <br />Exemption from Lawful Ga i, -. •- -nle <br />For Board Use Only <br />Fee Paid o25.CC <br />Check* rs/./6 0 c <br />Initals S6 <br />292S2e2' <br />Date Recd / /// <br />Organization Information <br />Organization Name <br />Evangelical Lutheran Good Samaritan Society <br />Previous lawful gambling exemption number <br />X- 04758 -98 -002 <br />Street City State Zip Code County <br />4800 West 57th Street Sioux Falls SD 57117 Minnehaha <br />Name of Chief Executive Officer <br />First Narrie <br />Dr. Judith <br />of organization (CEO) <br />Last Name <br />Ryan <br />Daytime Phone number of CEO <br />(605) 362 -3100 <br />Name of Organization i reasurer <br />First Name <br />Dan <br />Last Name <br />Holdhusen <br />Daytime Phone Number of Treasurer <br />(605) 362 -3355 <br />.: !Trype:pfNonprofit <br />Organization <br />.Check the box below which best describes <br />�yobf organization <br />r. - <br />roc ;.referral <br />SI Veterans <br />Religious <br />Cj Other nonprofit <br />Check the box that indicates the type of proof attached to this applicatiee <br />by your organization: <br />C IRS Vetter indicating income tax exempt status <br />0 Certificate of good standing from the Minnesota Secretary of State's office <br />❑ A charter shaMng you're an affiliate of a parent nonprofit organization <br />a Proof previously submitted and on fie wit the Gamdrng Control Board <br />Gambling Premises Information <br />Name of Estabfis`imont here gambling itvity will be conducted <br />The Venetian Inn - <br />Street City State Zip Code County <br />2814 Rice Street Little Canada MN 55113 Ramsey <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />October 18, 1998 <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br />*Bingo ER Raffles E 'Paddlewheels ® 'Pull -tabs • 'Tipboards <br />*Equipment for these activities must be obtained from a licensed distributor <br />Be sure the Local Unit of Govemment and the CEO of your organization sign <br />the reverse side of this application. ,, I ). <br />For Board Use Only <br />Date &Initials of Specialist <br />c1 <br />a `1 `5 <br />Page 4 <br />