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()AMENS OIV',:SION <br />Mail Station 315 <br />Sr-. Paul MN 55146- 3315 <br />LAWFUL GAMBLING EXEMPTION <br />FOR BOARD USE ONLY <br />INSTRUCTIONS: 1. Submit request for exemption at least '9Q 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. Thecopies 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 />Little Canada Canadian Days <br />Number of Members <br />a0 <br />License Number (tf currently or previous., <br />licensed) and /or permit number. N. 6- ^^rte - / _ ^1 <br />l/ ( lD J <br />Ahrens <br />515 Little Canada Rd <br />Ciry <br />Little Canada <br />State <br />MN <br />bp <br />55117 <br />County <br />Ramsey <br />Chief Execunve Officer's Name <br />Ray Hanson <br />Phone Number <br />(612 ) 484 -8846 <br />Manger; Name <br />Phone Number <br />( ) <br />Type of Organization <br />❑ Fraternal ❑ Veterans <br />❑ Religion IrOther Nonprofit Organization <br />Attach proof of three years existence <br />If Omer Nonprofit Orgamzanon (Check One and attach proof of nonprofit status). <br />❑ IRS Designation <br />0 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, Drawing(a) <br />April 30,1989 <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 <br />Cost of Prizes <br />Profit <br />Market Value <br />of Prizes <br />Bingo <br />Raffles <br />X <br />Paddlewheels <br />Tipboards <br />Pull-Tabs <br />Use of Profit <br />Annual Celebration <br />Dtalnbutor From Whom Gambling Equipment Acquired <br />'Distributors License No. <br />I affirm all information submitted to the Board is true, <br />accurate and complete. <br />e •triter Signature <br />Date <br />I affirm all financial information submitted to the Board is true, <br />accurate, and complete. <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 ben served with notice that this <br />application will be reviewed by the charitable Gambling Control Board and will become effectiveaays from the date of receipt <br />(noted below) by the City or County, unless a resolution of the local governing body is passed which specifically disallows such <br />activity and a copy of that resolution is received by the Charitable Gambling Control Board with in-09daysof the below noted date. <br />CITY OR COUNTY TOWNSHIP <br />Name of Local Governing Body (City or County) <br />CITY OF LITTLE CANADA <br />Signature 1 Person Renewing Application <br />,2 <br />i <br />r <br />CITY CLERK <br />Township Name (Mum be notified when County is the approwq body) <br />Signature of Person Receiving Application <br />4/6/89 <br />Date Received <br />Title Date Received <br />CG-00020.02 (8/88) <br />White — Board na�— Board returns to Organization to complete shaded areas. <br />Pink — Organization P a g oltl Ciry or County <br />