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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 />rganizatioi Information' <br />Organi ation Name <br />,U <br />A.,/n/ rep <br />Street City <br />/9 / *rte ,#E �� (4t c <br />Name of Chief Exedutive Officer of organization (CEO) <br />First Name Last Name <br />Name of ot organization Treasu er <br />First Name Last Name <br />I Previous lawful gambling exemption number <br />47..6299-e/ <br />S ate <br />Zip Code <br />caia4/ <br />County <br />r <br />�eSe7 <br />Daytime Phone number of CEO <br />(4/A 996b <br />Daytime Phone Number of Treasurer <br />(6 /z) A /g /t2z3Y <br />Check the box below which best describes <br />your organization <br />Fratemal <br />0 Veterans <br />El Religious <br />fSZf Other nonprofit <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />J IRS letter indicating income tax exempt status <br />Certificate of good standing from the Minnesota Secretary <br />of State's office <br />�JA charter showing you're an affiliate of a parent <br />' `nonprofit organization <br />Eroof previously submitted and on file with the Gambling Control <br />Board <br />Gambling Premises Information <br />Name i o l <br />Establishment where gambling activity will be conducted li <br />ege <br />Street / // <br />X2,8/`7 iC e ,C4 ,C iT7`.�e 4,40/4 <br />City State Zip Code <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />$/4-96 % y -tea 9� <br />County <br />774 a//J i se% <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br />Bingo Raffles 1l Paddlewheels Pull -tabs Tipboards <br />Be sure the Local Unit of Govemment and the CEO of your organization sign <br />the reverse side of this application. <br />Rage 21 <br />For Board Use Only <br />Date & Initials of Specialist <br />