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1821 University Avenue <br />St. Paul, MN 55104 -3383 <br />(6121642 -0555 <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 />financial information, sign and date the form, and return to the Board within 30 days. <br />PLEASE TYPE <br />Organization Name <br />Little Canada/Vadnais Heights; Division Surbaban Area Chamber of Commerce <br />License Number St currently of pfeuqu5ly licensed) <br />Address <br />2489 Rice Street <br />City, County, State, Zip Code <br />St. Paul, Minnesota 55113 <br />Chief Executive Officer's Name <br />Louis Anderson <br />Phone Number <br />483 -6600 <br />Manager's Name <br />Sharron Clasen <br />Phone Number <br />483 -4354 <br />Type of Organization <br />❑ Fraternal ❑ Veterans <br />❑ Religion El Other Nonprofit Organization <br />If Other Nonprofit Organization (Check One) <br />❑ IRS Designation <br />® Incorporated with Secretary of State <br />❑ Affiliate of Parent Nonprofit Organization <br />Name of Premises Where Activity Will Occur <br />The Venetian Inn <br />Datels) of Activity <br />11/2/86 <br />Premises Address <br />2814 Rice Street - St. Paul, Minnesota 55113 <br />Games <br />Yes <br />No <br />Gross Receipts <br />Value of Prizes <br />Expenses <br />Profit <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />X (Possibly) <br />Pull -Tabs <br />Use of Profit <br />Speakers and Educational Seminars as provided by the Chamber <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 />Chief Executive Officer Signature <br />Date <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) <br />City of Little Canada <br />Township Name (Must be notified when County is the approving bodyl <br />Signa ure of Pers n Receiving Application <br />-'77* <br />itle <br />City Clerk <br />— J.n.saph f: Chlehark <br />Date Received <br />9/18/86 <br />Signature of Person Receiving Application <br />Title Date <br />CG-00020.01 (4!86) <br />1 <br />White -- Board <br />Canary Board returns to Organization to keep <br />Pink — Organization Gold — City or County <br />22 <br />