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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 60 days prior to the occasion. <br />2. When completing form, do not complete shaded areas until after the activity. <br />3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be returned <br />with an exemption number added to the form. When your activity is concluded; complete the financial <br />information, sign and date the form, and return to the Board within 30 days. <br />PLEASE TYPE <br />Organization Name <br />Little Canada Recreation Association, Inc. <br />Number of Members <br />51 <br />License Number (if currently or previo sly <br />licensed) and /or permit number. <br />Not Licensed <br />Address <br />515 East Little Canada Road <br />City <br />Little Canada <br />State <br />NN <br />Zip <br />55117 <br />Co My <br />Ramsey <br />Chief Executive Officer's Name <br />Steve Moreton <br />Phone Number <br />(612 450 -5046 , <br />Manager's Name <br />Steve Morelar_. , <br />Phone Number <br />(612 )450 -5046 <br />Type of Organization <br />O Fraternal ❑ Veterans <br />❑ Religion EN Other Nonprofit Organization <br />Attach proof of three years existence <br />If Other Nonprofit Organization (Check One and attach proof of nonprofit status),. - -. <br />❑ IRS Designation <br />n Incorporate with Secretary of State <br />❑ Affiliate of Parent Nonprofit Organization <br />Name of Premises Where Activity Will Occur <br />Basement of Little Canada Fire Depattment <br />Date(s) of Activity. Orawing(s) <br />Jan, 14 &15, 198' <br />Premises Address <br />440 E. Little Canada Rd. <br />City <br />Little Canada <br />State <br />MN <br />Zip <br />55117 <br />County <br />Ramsey <br />Game <br />Yes <br />No <br />Gross Receipts <br />Expenses <br />Cost of Prizes <br />Profit <br />Market Value <br />of Prizes <br />Bingo <br />b <br />Raffles <br />X <br />Paddlewheels <br />X <br />Tipboards <br />X <br />Pull -Tabs <br />X <br />Use of Profit <br />Profits will be used to supplement the City's recreation program <br />Distributor From Whom Gambling Equipment Acquired <br />Distributor's License No. <br />I affirm all information submitted to the Board is true, <br />accurate, and complete. <br />/727c/cLA <br />11 -14 -88 <br />Chief Executive Officer Signature <br />Date <br />I affirm all financial information. submitted to the Board is true,. <br />accurate, and complete. <br />Chief Executive Officer Signature <br />Date <br />ACKNOWLEDGEMENT 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 that this <br />application will be reviewed by the charitable Gambling Control Board and will become effective 60 days from the date of receipt <br />(noted below) by the City or County, unless a resolution of the local governing body is passed which specifically disallows such <br />activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 days of the below noted date. <br />CITY OR COUNTY TOWNSHIP <br />Name of Local Governing Body (City or County) <br />City of Little ("!•path <br />Township Name (Must be notified when County is the approving body) <br />Signature of Person Receiving Application <br />Signature of Person Receiving Application <br />Title <br />Clerk/ treasurer <br />Date Received <br />.�11- 1'i -8J <br />Title <br />Date Received <br />CG-130020-02 (8/88) <br />White — Board <br />Pink — Organization <br />page 8 `' Canary — Board returns to Organization to complete shaded areas. <br />Gold — City or County <br />