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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 />Organization Name <br />,v& 17 fgt'L G/'0/VS <br />Previous lawful gambling exemption number <br />Street City S <br />£'U, JOn ND, 57 fAtit /IA/ <br />ate Zip Code County <br />_c_; * ? 69,45-e7/ <br />Name of Chief Executive Officer <br />First Name <br />Mt/Z.- <br />of organization (CEO) <br />Last Name <br />A,k ez2c- t--'i- E <br />Daytime Phone number of CEO <br />(oi z) y 6, L I — lei-53 <br />Name of Organization Treasurer <br />First Name <br />ic. CZ. r <br />Last Name <br />c- t, 'LTC LI r <br />Daytime Phone Number of Treasurer <br />( ) , - 4-ys_z— <br />Type of Nonprofit Organization <br />Check the box below which best <br />your organization <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 />IRS letter indicating <br />Epertificate of good <br />of State's office <br />DA charter showing <br />nonprofit organization <br />d'roof previously <br />Board <br />Fraternal <br />0 Veterans <br />Religious <br />g <br />is Other nonprofit <br />Gambling Premises Information <br />Name of Establishment where gambling activity will be conducted <br />VF/6r/4 4/ j /t-th/ <br />Street City State Zip Code County <br />-2ly /e)e-E ST Li Ties CA/4M MA/ ' y /13 ,ertl/ri5tfY <br />Date(s) off activity (for raffles, indicate the date of the drawing) <br />`- %�.-0.-/-f 3 / / /7th; <br />Check the box or boxes hich indicate the type <br />of gambling activity your <br />[ Pull -tabs <br />organization <br />will be conducting <br />• Bingo aRaffles • Paddlewheels <br />• Tipboards <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 />/ / <br />