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MLNNES0rA DEPARFMf:Nr Of Rf :VhNIUL <br />GAMING DIVISION <br />Mail Station 3315 <br />St. Paul MN 55146 -3315 <br />LAWFUL GAMBLING EXEMPTION <br />FOR BOARD USE ONLY <br />'lc <br />INSTRUCTIONS: 1. Submit request for exemption at least GO 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 />U • ^ , 27 C ' O <br />Numoer al MemOels <br />.1-_-_5- <br />License Number of currently or previously <br />licensed) an ror permit numoer. <br />Address <br />177z� G 11 ALE NI. <br />City <br />FLv/,,Qcn -f <br />State <br />ti�� <br />Zip <br />a5 4717 <br />County <br />j-fC,••tk:)i relic' <br />Chief Executive Officer's Name <br />7TEUE rtrlti; tAc- I <br />Phone Number <br />( Piz. )475 - +4o <br />Manager's Name <br />Ft;tr' V r1r -re.o <br />Phone Number <br />(640, 4 3-a -02- <br />Type of Organization <br />❑ Fraternal Veterans <br />❑ Religion ccOther Nonprofit Organization <br />Attach proof of three years existence <br />11 Other Nonprallt Organization (Check One and attach proof of n nprolit 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 />vcNET 1IN N fk i <br />Date(s) of Activity, Drawing(s) <br />mfict,-t Izi iq' <br />Premises Address ' ^/ <br />Z /I -1 Q ca i <br />City ��r-�� / zy p <br />LM-1 E c.AN/lpA <br />State l 1 <br />01 IC <br />Zip <br />5S717 <br />Coun �ty'[� <br />/�-/I y <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 />Raffles <br />I0ICOO. op <br />95-60. do <br />€SCD.CO <br />45co.c0 <br />Paddlewheels <br />Tipboards <br />Pull -Tabs <br />Use of Profit <br />Sctfci_.f es -} (P Fge Q.) (14 1 <br />t3 CITY C ST Pl9VL SiJh'UtZe?S <br />Distributor From Whom Gambling Equipment Acquired <br />Nok)C <br />Distributors License No. <br />I affirm all information submitted to the Board is true, <br />accurate, and commpleje. <br />cc /77. Ads— /935, <br />Chief Exec )we Officer Signature 1 Dale <br />I affirm all financial information submitted to the Board is true, <br />accurate and coommple e. <br />e Officer Signature Date <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />1 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 (?0 days from the date of receipt <br />(noted below) by the City or County, unless a resolution of the local governing body is passed wh ch specifically disallows such <br />activity and a copy of that resolution is received by the Charitable Gambling Control Board within gH days of the below noted date. <br />3C <br />CITY OR COUNTY TOWNSHIP <br />Name of Local Governing Body (City or County) <br />GTTY (1F 1 TTTI E CANA <br />Signature of Person Receiving Application <br />le Date Received <br />2/6/89 <br />Township Name (Must be notified when County is the approving body) <br />CLERK - TREASURER <br />ignature of Person Receiving Application <br />Crate Received <br />C0.00020.02(8/88) <br />While — Board Canary — Board returns to Organization to complete shaded areas. <br />Pink — Organization Page 33 Gold — city or County <br />