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CG220 <br />(Rev. (8/89) <br />Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />For Office Use Only <br />Fill in the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing, <br />Name and Address of Organization <br />Organization <br />5rl 67AI 1- W/%—'70t c(,44 VOL 1-)7A -NS <br />Street City State Zip code <br />717 <br />currentprevbus license number <br />%70 6C I C—t ter/ , 5717A1/// hN <br />Chief executive officer Phone Manager <br />) <br />currenuprevious exempt number <br />County <br />Type of Non-profit Organization <br />Phone <br />( ) <br />Years in existence <br />❑ Fraternal <br />Attach proof of three years or more of existence. Number of active members <br />❑ Religious ❑ Veterans ❑ Other non - profit <br />1110.1 <br />N you checked box for other nonprofit, check one of the following and attach proof of nonprofit status <br />❑ IRS designation ❑ Incorporated with Secretary of State ❑ Affiliate of parent nonprofit organization (charter) <br />Gambling Site <br />Name of site where activity will take place ,t <br />Street City <br />State <br />Zip code <br />County <br />Date(s) of activity <br />Tunes of Games <br />'financial Report <br />Raffles <br />Paddlewheels <br />11 <br />Pull -tabs <br />How will profit be used: <br />................... <br />I declare all information submitted to the Department of Gaming <br />is true, accurate, and complete <br />phief executive nffir en einnature Date <br />hag YP <br />hff(!`Pl <br />I(fnaHilf <br />Local Government Acknowledgement <br />1 have received a copy of this application. This application will be reviewed by the Department of Gaming and will become effective 30 days <br />from the date of receipt by the city or county, unless the local govemment passes a resolution to spedfically prohibit the activity, A copy of that <br />resolution must be received by the Department of Gaming within 30 days of the date filled in below. Cities of the first class have 60 days in <br />which to disallow the activity. <br />City or County <br />Ci or county n- e <br />�/ <br />Sivas a of person receiving application <br />Title <br />Date received <br />Township <br />Township name <br />Signature of person receiving application <br />Title <br />Date received <br />w`` Board <br />- a°a.wn Mali this application and fee of $25 (check made out to Commissioner of Revenue) to: <br />Ytllwv- 8owel laimadedyo uMnb Department of Gaming - Gambling Control Division <br />complete orb <br />Gold -o County Mail Station 3315 <br />St. Paul, MN 55146 -3315 Page 15 <br />