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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 tdthe occasion. <br />2. When completing form, do not cornpl'ete shaded areas unt {I after the activity. <br />3. Give the gold copy to the City or County. Send the .remainirtg'copies to the Board. The copies will be <br />returned with an exemption numbe 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 <br />ROSeYiI,],e Area Middle School Y3b.i. <br />Number of Members <br />Ott, <br />License Number Of currently or previously <br />enselantlor permit number. O ,L._.:JC'. <br />Address <br />51 'iAaL Count;? Rd. B-2, <br />City -'- "" <br />a__l2 ., ,..:l Ei El:: <br />State <br />_. <br />Zip <br />J_`1!. <br />Co mty <br />.:.IIH , <br />Chief Executive Officer's Name <br />Ilona 'ouch., Pr: si.denk <br />Phone <br />l ^_ (';31. -122 <br />Manager's Name <br />.,an Cooaar <br />Phone Number <br />=. i, 1 : ;n.' <br />Type of Organization <br />El Fraternal ❑ Veterans <br />El Religion C'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 />❑ Incorporate with Secretary of State <br />L3 Affiliate of Parent Nonprofit Organization <br />Name of Premises Where Activity Will Occur <br />Cafcter-ia; Roseville Area Middle Schoc.t <br />Date(s) of Activity, drawing(s) <br />_'- 1'J'-{:' <br />5 V3; :i.-9- <br />Premises Address <br />ii; - cotmtr Rd. u -2 <br />City <br />LIcd'2 .....- ., .. <br />State <br />2111 <br />Zip <br />_;11- <br />County <br />iE:HE EJ° <br />Game <br />Yes <br />No <br />Gross Receipts <br />Expenses and <br />Cost of Prizes <br />, <br />\. Profit <br />Market Value <br />of Prizes <br />Bingo <br />Raffles.- <br />- <br />Paddlewheels <br />Tipboards <br />Pull -Tabs <br />Use of Profit <br />Distributor From Whom Gambling Equipm‘nt Acquired <br />I affirm all information submitted to the Board is true, accor- <br />ate, and complete. <br />/.()'- / / <br />Chief Executive Officer Signature <br />Date <br />I affirm all financial information <br />true, accurate, and complete. <br />Chief Executive Officer Signature <br />Distributor's License No. <br />SCI,: <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BO[ <br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit hay <br />that this application will be reviewed by the Charitable Gambling Control Board and will become <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 />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 Date Received <br />Title Date <br />CG- 0002001 (6187) <br />White - Board Canary -- Board returns to Organization to complete shaded areas. <br />Pink - Organization Gold — City or County <br />Page 8 <br />