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LG220 <br />Rev06 /95 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 />Organization Name <br />(2�C/ L) IL.� ,L 1 it,;( I :: G t /,,,,, ; ; <br />Previous lawful gambling exemption number <br />Street City S <br />,. l �- <br />/ 'jc �;1 . r1. Ju.r /l <br />ate Zip Code County <br />- — <br />;r_r/ , _` 51/3 K# fi {y <br />Name of Chief Executive Officer <br />First Name <br />MC /14EL <br />of organization (CEO) <br />Last Name <br />G(/ / /0/-72 E <br />Daytime Phone number of CEO <br />(era) yyy- 6_53V <br />Name of Organization Treasu <br />First Name <br />7) 0/0/1G1J <br />er <br />Last Name <br />Daytime Phone Number of Treasurer <br />) y14- fig? <br />aSS <br />Type of Nonprofit Organization <br />Check the box below which best <br />your organization <br />(---1 Fraternal <br />(� Veterans <br />Religious <br />describes <br />Check the box that indicates <br />by your organization: <br />the type of proof attached to this application <br />income tax exempt status <br />standing from the Minnesota Secretary <br />you're an affiliate of a parent <br />submitted and on file with the Gambling Control <br />I i IRS letter indicating <br />nCertificate of good <br />of State's office <br />QA charter showing <br />nonprofit organization <br />`n <br />I>q Other nonprofit <br />roof previously <br />Board <br />Gambling Premises Information <br />Name of Establishment where gambling activity will be conducted <br />19F/12 ET /A n) ._.T. !')!1) <br />Street City State Zip Code County <br />-17/ ee /: S7 47lti 2/ LI'(24/..) 14 4;1. ; 375 i )3 tM7SEc <br />Date(s) of activity (for affle <br />1f7 13 per <br />, indicate the date of the drawing) Da�vO,eS 8a eluEr <br />— ¢ 09 - 98 <br />-6."- 9,F <br />Check the box or boxe .which <br />ind' ate the type of gambling activity your organization will be conducting <br />[fl Paddlewheels ['p Pull -tabs 0 Tipboards <br />Bingo Raffles <br />Be sure the Local Unit of Government and the CEO of your organization sign <br />the reverse side of this application. <br />Page 7 <br />For Board Use Only <br />Date & Initials of Specialist <br />/ / <br />