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2 <br />V <br />2 <br />Minnesota Charitable Gambling ControVBo <br />Room N475 Griggs- Midway Building `o <br />1821 University Avenue <br />St. Paul, MN 55104 -3383 <br />(6121642 -0555 <br />11 ]2 <br />44 <br />dRECEE:vEn <br />JUL 251988 w <br />City of <br />Little Canada 0) <br />V <br />LAWFUL GAMBLING EXEMPTION <br />FOR BOARD USE ONLY <br />INSTRUCTIONS: 1. Submit request for exemption at le c e - ; leg the occasion. <br />2. When completing form, do not comp alite• as 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 <br />returned with an exemption number added to the form. When your activity is concluded; complete <br />PLEASE TYPE the financial information, sign and date the form, and return to the Board within 30 days. <br />Organization Name N <br />Nu^gb tot Members L <br />License Number (if currently or previously <br />Address C <br />City S <br />State Z <br />Zip C <br />County <br />Chief Executive Officer's Name P <br />Phone M <br />Manager's Name P <br />Phone Number <br />Type of Organization I <br />If Other Nonprofit Organization (Check One and attach proof of nonprofit status). <br />Name of Premises Where Activity Will Occur ( <br />()stets) of Activity, drawingls) <br />Premises Address C <br />City S <br />State Z <br />Zip C <br />County S <br />Game Y <br />Yes N <br />No - <br />: <br />:Expenses and . <br />Profit `" _ <br />...:1: .Market arket Value <br />Bingo X <br />X <br />7 `tiwY z t . � <br />SK..�ai Y <br />�� r -( <br />Raffles - <br />X : <br />- <br />Paddlewheels <br />X . <br />.1 ,' � / �� j <br />J <br />Use of Profit <br />Diistribuutor From {Whom Gambling Equipment Acquir&i <br />14 F +,i.V <br />Distributor's License No. <br />I affirm all information submitted to the Board is true, accor- <br />ate, andspmplete..r.Ze <br />7/21/88 <br />Chief Executive Officer Signature <br />Date <br />I affirm all financial information submitted <br />true, accurate, and complete <br />988 <br />to the Board is <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 <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 <br />Name of Local Governing Body (City or County) <br />City of Little Canada <br />Signal re of Person Re eiving Application Signature of Person Receiving Application <br />y Joseph G• Chlebeck <br />e Date Received Title <br />C erk— Treasurer 7/25/88 <br />TOWNSHIP <br />Township Name (Must be notified when County is the approving body) <br />PAGE -4- <br />Date <br />CG-00020-01 (6/87) <br />White — Board Canary — Board returns to Organization to complete shaded areas. <br />Pink — Organization Gold — City or County <br />