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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 />Organ' ation Name Previous lawful gambling exemption number <br />[/G< /6, .t/ 67D 99 - D/ <br />Street / �} City/ slate Zip Code County <br />/4 9� ,4 /e ,4 S fa "zu 0.4-3-,p/ �i2/el <br />Name of Chief Exe live Officer <br />First Name <br />ectlity&S ' <br />of organization (CEO) <br />Last Name <br />r_5(13/4/,‘/(2.47.14W <br />Daytime Phone number of CEO / <br />(1/2) qs- 996 <br />Name of Organization I reasurer <br />First Name <br />• <br />—76:22<-1 <br />Last Name <br />762,04 <br />Daytime Phone Number of Treasurer <br />Yt <br />(6C) I/P/ -27M/ <br />Type of Nonprofit Organization <br />Check the box below which best describes <br />your organization <br />Fratemal <br />El Veterans <br />mg Religious <br />(,�"j Other nonprofit <br />7 <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />[� IRS letter indicating income tax exempt status <br />Epertificate of good standing from the Minnesota Secretary <br />of State's office <br />cAA charter showing you're an affiliate of a parent <br />nonprofit organization <br />Droof previously submitted and on file with the Gambling Control <br />Board <br />Gambling Premises Information <br />Name of Establishment where gambling activity will be conducted <br />Street City State Zip Code , - County <br />// �% <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />74 -9/7 I 'cgD- 97 <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br />Bingo Raffles Paddlewheels Pull -tabs 0 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 7 <br />For Board Use Only <br />Date & Initials of Specialist <br />/ / <br />