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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 />financial information, sign and date the form, and return to the Board within 30 days. <br />PLEASE TYPE <br />Organization <br />24/'F O� // V V ?ES, DC ijQ <br />G. 04 uivT6E 4J%te//4 <br />Cit Coun y, State, Zip Code <br />4NroRE_ v�E/ <br />License NV ficensedl <br />0/ 47f / <br />Ss- /2-6 <br />Address <br />/L 4 o OW 2• e4Vo <br />/IChief xecutive Officer's Name <br />.✓ l9vt— <br />P one Number <br />'J24_. —// <br />Mana 's Name <br />/gF7-rV /7 /2-1-.ER <br />Phone Number . <br />4t4 -34 07 <br />Type of Organization <br />❑ Fraternal ❑ <br />Veterans <br />Other Nonprofit Organization <br />0 Other Nonprofit Organization (Check One) <br />❑ IRS Designation <br />'Incorporated with Secretary of State <br />❑ Affiliate of Parent Nonprofit Organization <br />• Religion <br />Na of Premises Where Activity Will Occur <br />Nan <br />of ENE- riatl� /N N <br />Datels) of Activity <br />`uN- <br />PreesA dde /3r <br />tO <br />g. <br />4 /yTl� e,9N/vr / l 3 <br />Per /2/ / 7 <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 />l/ <br />Pull -Tabs <br />, <br />Use of Profit <br />Distributor From Whom Gambling Equipment Acquired <br />Disuibutor's License No. <br />I affirm all information submitted to the Board is true, accu <br />rate, and complete. <br />I affirm all financial information submitted to the Board is <br />true, accurate, and complete. <br />Chief Executive Officer Signature <br />Date <br />Chief Executive Officer Signature <br />Date <br />ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY <br />• <br />!hereby acknowledge receipt of a copy of this application. By acknowledging receipt, 1 adfliit 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 notibed when County is the appmvmg body) <br />W hne - <br />Sgnauu i of Person Rocervmll Application Signature of POI son Receiving Application <br />e - �� -r <br />City Clerk 10/8/86 Dale Received 1Pie Date <br />CG 00020 111 of 861 <br />((Udall ('an;uy 110,11(i WHIMS 100naOlzetioO to ecep <br />Pin( °HillW.1110H Gold City 01 Cnunly <br />