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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 Maras.. -. <br />PO P <br />S City State Zip Code County <br />P, , Bcx. . 2-- Nra-sFe 2 mit) .S5 /o9 gf-ai <br />/ tin <br />- Previous lawfakgambling exemption number <br />Name of Chief Executive Officer of organization (CEO) <br />First Name Last Name <br />Name of Organization Treasurer <br />First Name Last Name <br />Ito IF <br />O v'e r i e <br />Daytime Phone number of CEO <br />7 7) 77 V <br />Daytime Phone Number of Treasurer <br />( ) a9G -eta <br />Check the box below which best describes <br />;your organization <br />Q Fratemal <br />Q Veterans <br />TEl Religious <br />frill Other nonprofit <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />Q IRS letter indicating income tax exempt status-.• <br />Q Certificate of good standing from the Minnesota Secretary of State's office. <br />CIA charter showing you're an affiliate of a parent nonprofit organization <br />Proof previously submitted and on file with the Gambling Control Board <br />ambling Premises- Informatiom <br />Name of Establishment where gambling activity will be conducted <br />VerJ e 7L /a SNP/ <br />Street <br />City <br />State Tip Code County <br />C'04-7aola (I N S S //7 iC19nisey <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />7 <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br />Q *Bingo Raffles Q 'Paddlewheels Q "Pull -tabs Q 'Tipboards <br />*Equipment for these activities must be obtained from a licensed distributor <br />Be sure the Local Unit of Government and the CEO of your organization sign <br />the reverse side of this application. <br />Page 8 <br />For Board Use Only <br />Date & Initials of Specialist <br />