04-27-1988 Council Agenda - Laserfiche WebLink

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Minnesota Charitable Gambling Control Board Room N475 Griggs- Midway Building 1821 University Avenue St. Paul, MN 55104 -3383 (612) 642 -0555 LAWFUL GAMBLING EXEMPTION FOR BOARD USE ONLY INSTRUCTIONS: 1. Submit request for exemption at least 30 days prior to the occasion. 2. When completing form, do not complete shaded areas until after the activity. 3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be returned with an exemption number added to the form. When your activity is concluded; complete P the financial information, sign and date the form, and return to the Board within 30 days. LEASE TYPE Organization Name QPm FMO B asi/I -Ds ) b i' c (r O Number of Members uJ 67 License Number (if currently or previously licensedland;or permit number. AJ�rl 003_6/ d Address P 0 8,, )70)i City ti fetid State }W Zip 6- s)) 7 Coun,tyyy Kam se y Chief Executive Officer's Name be Gre5 o hoehc.tJ Phone (471)+ h/ 1 -12S) Manager's Name Alc,) Emor3 Phone Number 4)a) ye7— ifu ) Type of Organization ❑ Fraternal ❑ Veterans ❑ Religion ❑ Other Nonprofit Organization Attach proof of three years existence. If Other Nonprofit Organization (Check One and attach proof of nonprofit statusl. [.)IRS Designation ❑ Incorporate with Secretary of State ED Affiliate of Parent Nonprofit Organization Narne of Premises Where Activity Will Occur VfeneA,GN —1n-) Date(s) of Activity. drawing(s) vune S /gO J Premises Address ti`sid to R:ee sf City (� �i Pa,t.t State State Zip 6s)13 County RQmse;J Game Yes No Gross Receipts Expenses and Cost of Prizes Profit Market Value of Prizes Bingo ¥ Raffles x Paddlewheels x Tipboards x Pull -Tabs X Use of Profit /� �J FOc eO bkAfef)its Distributor From Whom Gambling Equipment Acquired Distributor's License No. I affirm all information submitted to the Board is true, accor- ate, a complete. Chief Executive Officer Si - naturd L{ Tv 1 affirm all financial information submitted to the Board is true, accurate,' and complete. Chief Executive Officer Signature Date ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice that this application will be reviewed by the Charitable Gambling Control Board and will become effective 30 days from the date of receipt (noted below) by the City or County, unless a resolution of the local governing body is passed which specifi- cally disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30 days of the below noted date. CITY OR COUNTY Name of Local Governing Body (City or County) Township Name (Must be notified when County is the approving body) City of Little Canada TOWNSHIP Signature of Person Rec iving Application Ti Clerk— Treasurer Pa Signature of Person Receiving Application e 82 4/ 2 1 / nte Received Title Dare rnn „r, - Rnard romroc to Ornanbatinn to complete shaded areas.