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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 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 />the financial information, sign and date the form, and return to the Board within 30 days <br />PLEASE TYPE <br />Organization Name <br />Little Canada Canadian Days <br />Number of Members <br />20 <br />License Number (if currently or previously <br />licensed) and: or permit number. <br />Address <br />515 Little Canada Rd <br />City <br />Little Canada <br />State <br />MN <br />Zip <br />55117 <br />County <br />Ramsey <br />Chief Executive Officer's Name <br />ay Hanson Pres /Cynthia O'Banion <br />Phone Ray 484- 8846tanager'a <br />- 484 -3761 <br />Name <br />Phone Number <br />( ) <br />Type of Organization <br />❑ Fraternal ' ❑ Veterans <br />❑ Religion E 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 />❑ Affiliate of Parent Nonprofit Organization <br />Name of Premises Where Activity Will Occur • <br />Venetian Inn <br />Date(s) of Activity. drawingls) <br />Apr 2 17, 198E <br />Premises Address <br />2814 Rice <br />City <br />Little Canada <br />State <br />MN <br />Zip <br />55113 <br />County <br />Ramsey <br />Game <br />Yes <br />No <br />Gross Receipts <br />:Expenses and <br />Cost of Prizes <br />Profit '�•` <br />Market Value q <br />'''?of Prizes ' <br />Bingo <br />MF <br />` tk tE - a <br />y s r <br />a <br />Raffles <br />/\ <br />Paddlewheels <br />Z ,x•.,. kr > <br />4 \ <� <br />f <br />>�• mat rl -'j <br />Ti boards <br />�/v <br />t <br />C. <br />) <br />Pull -Tabs <br />i < <br />Use of Profit <br />Distributor From Whom Gambling Equipment Acquired <br />Distributor's License No. <br />I affirm all information submitted to the Board is true, accor- <br />ate, and complete. <br />Chief Executive Officer Signature Date <br />I affirm all financial informs'' <br />true accurate and comptetc <br />Chief Executive Officer Signature <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 />TOWNSHIP <br />Name of Local Governing Body (City or County) <br />City of Little Canada <br />Township Name. (Must he notified when County is the approving body) <br />Signature of Person eceiving Applicatio <br />�iitlef <br />e4-reX <br />/Date Received <br />Signature of Person Receiving Application <br />Title <br />Date <br />CG-00020•0116/87) <br />White — Board Canary — Board returns to Organization to complete shaded areas. <br />Pink — Organization Gold — City or County <br />Page 2 <br />