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LG220 <br />Rev06/96 <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 />/Orr'gganization Name //. .. . ...... ... <br />th Scrbatbaot) evens -zq tons <br />....Previous lawful gambling exemption number <br />Y <br />Street C Zip County <br />j State <br />07781 facet/4914n S7Z,eeef Pouw //e OA/ S5'//5 -2Vd , /C4 set <br />Name of Chief Executiv Officer <br />First Name <br />ICAS /Mne <br />, <br />of organization (CEO) <br />Last Name <br />Z na fee <br />Daytime Phone number of CEO r <br />0/2) zits-/o0 <br />acme of Organization Treasurer <br />First Name <br />l%!4'gi <br />Last Name <br />Sanic/!St— <br />Daytime Phone Number of Treasurer <br />y <br />(/o /a2) 0295 - 34/33 <br />Type of Nonprofit Organization <br />Check Check the box below which best <br />your organization <br />describes <br />Check the box that indicates <br />by your organization: <br />Q IRS letter indicating income <br />❑ Certificate of good standing <br />A charter showing you're <br />the type of proof attached to this application <br />tax exempt status <br />from the Minnesota Secretary of State's office <br />an affiliate of a parent nonprofit organization <br />and on file with the Gambling Control Board <br />Fratemal <br />Veterans <br />Religious <br />K Proof previously submitted <br />Other nonprofit <br />Gambling Premises Information <br />Name of Establishment where gambling activity will be conducted <br />-I—A 2 V tedian rn e7 <br />Street City State Zip Code County <br />02 (i /"( e c e ' C/a 1e7L A,V /e eife4, M/4/7 55//3 le-Sel <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />Oc6ahec_ £, /997 <br />Check the box or boxes which <br />D *Bingo fiq' Raffles <br />indicate the type of gambling activity your organization will be conducting <br />*Paddlewheels EJ *Pull -tabs 0 *Tipboards <br />for these activities must be obtained from a licensed distributor <br />*Equipment <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 />Page 4 <br />