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Minnesota Charitable Gambling Control Board <br />Room N475 Griggs- Midway Building <br />1821 University Avenue <br />St. Paul, MN 55104 -3383 <br />(612) 642 -0555 <br />LAWFUL GAMBLING EXEMPTION <br />FOR BOARD USE ONLY <br />INSTRUCTIONS: 1. Submit request for exemption at least 30 days prior to the occasion. <br />2. When completing form, do not complete shaded areas. <br />3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be <br />returned with an exemption number added to the form. When your activity is concluded; complete the <br />PLEASE TYPE financial information, sign and date the form, and return to the Board within 30 days. <br />Omar atop ante <br />{ !lame �j b J- C- <br />I.ort "l�tl a� U KS r tt e s�' cc `t <br />ticons'p Number stepsons or premaulylicensoll <br />/( -'r iI 1 c'r' cl <br />dress /� it x....� <br />%� �. lick 17011/ s I. Pa � /. <br />_-, <br />City. County, Shale, ZIP Cpde 1 <br />/ <br />Chief <br />Type <br />❑ <br />El <br />Executive Officer's Naine <br />U /LI /1 I r� y (t-l.J 1J <br />Phone Number <br />CL1 -) "' -r ID L� <br />Manager's Name �� 7Phone <br />If Other Nonprofit Organization (Check Onel <br />I: 1 IRS Designation <br />Incorporated with Secretary of State <br />❑ Affiliate of Parent Nonprofit Organization <br />Number <br />, <br />of Organization <br />Fraternal ❑ Veterans <br />Religion I Other Nonprofit Organization <br />Name of Premises Where Activity Will Occur <br />Datels) of Activity <br />Premises Address <br />'dl�/y X), P.:.cF Sl- L ( H If (r + (t I �,t l_. fS7/7 <br />Games <br />Yes <br />No <br />Gross Receipts <br />Value of Prizes <br />Expenses <br />Profit <br />Bingo <br />X <br />Raffles b i K <t..e:- <br />Paddlewheels <br />X <br />Tipboards <br />Pull -Tabs <br />Use of Profit <br />Distributor From Whom Gambling Equipment Acquired <br />Distributor's License No. <br />I affirm all information submitted to the Board is true, accu <br />rate, and complete. <br />I <br />� l- i._ i. t' i.�l � . ,,, t l i 4 <br />bate <br />Chief. Executive Officer Signature <br />I affirm all financial information submitted to the Board is <br />true, accurate, and complete. <br />Chief Executive Officer Signature <br />Date <br />ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY <br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice <br />that this application will be reviewed by the Charitable Gambling Control Board and will become effective 30 days from the <br />date of receipt (noted below) by the City or County, unless a resolution of the local governing body is passed which specifi- <br />cally disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30 <br />days of the below noted date. <br />CITY OR COUNTY TOWNSHIP <br />Name of Local Governing Body (City or County) Township Name (Must be notified when County is the approving body) <br />City of Little Canada <br />Signatu of Person Receiving Application <br />1 <br />• 'Date Received <br />City Clerk 5115/86 <br />Signature of Person Receiving Application <br />Tide <br />Date <br />CC-00020-0114/861 <br />White — Boerd Chimp, - Board returns to Organization to keep <br />Pink -- Organization Gold -- City or County <br />47 <br />