Laserfiche WebLink
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 />Nei, sr, ,0 1/4- L/ opt/: <br />Previous lawful gambling exemp' n number <br />°i.3r o i r n <br />Street City Sate Zip Code County <br />,ilvy sr m g ` frzsv 3-37(29 <br />Name of Chief Executive Officer <br />First Name <br />ALt 4 p <br />of organization (CEO) <br />Last Name <br />ZUc,e4hFLI g <br />Daytime Phone number of CEO <br />(i12) q 4- 2-3 6� <br />Name of Organization Treasurer <br />First Name <br />POLE <br />Last Name <br />e V Ete z_1� <br />Daytime Phone Number of Treasurer <br />(4i?) '779 _577/5-2-- <br />Type of Nonprofit Organization <br />Check the box below which best <br />your organization <br />CEL Fraternal <br />Q Veterans <br />describes <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 />QCertificate of good standing from the Minnesota Secretary <br />of State's office <br />QA charter showing you're an affiliate of a parent <br />nonprofit organization <br />=Proof previously submitted and on file with the Gambling Control <br />Board <br />Religious <br />Other nonprofit <br />Gambling Premises Information <br />Name of Establishment where gambling activity will be conducted <br />l/E'/✓E'n/fti' 1 Nit/ <br />Street <br />ci? /1-7 c.—e_.11--. <br />—e k-' <br />City State Zip Code County <br />ir i � c let_ . 9`7( -�c-- S57/3 757,-,'xicz-e_ <br />`,C <br />Date(s) of activity (or raffles, indicate the date of the drawing) <br />Av'&, Z7`, 1q9 L <br />Check the box or boxes which <br />indicate the type of gambling activity your <br />Q Paddlewheels Q Pull -tabs <br />organization <br />will be conducting <br />• Bingo fa Raffles <br />mu Tipboards <br />Be sure the Local Unit of Govemment and the CEO of your organization sign <br />the reverse side of this application. <br />Page 3 <br />For Board Use Only <br />Date & Initials of Specialist <br />/ / <br />