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CG220 <br />(Rev. (8/69) <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 currenvprevaus license number <br />TEA. NotlUUH ,C4/0 £usf,>,r-ss (I CI <br />Street City State Zip code <br />1: 0 i 80A / 7 0/y st, »/Xu 1, 1//V 3.1/ 17 <br />Chief executive officer Phone Mapeger <br />L /00r9,f Biz f?6 u ,;t (Oz.) 1/4 0963 tic ;,.1 .4. %::Lseh_e, -r <br />1. <br />Type of Non-profit Organization <br />currenvprevious exempt number <br />County <br />£Atil sty <br />Phone <br />c - <br />0 c, i.. <br />Years in existence <br />❑ Fraternal <br />14- <br />Attach proof of three -years or more of existence. Number of active members <br />❑ Religious ❑ Veterans ❑ Other non - profit <br />90 <br />If you checked box for of er nonprofit, check one of the following and attach proof of nonprofit status <br />❑ IRS designation AlIncorporated with Secretary of State ❑ Affiliate of parent nonprofit organization (charter) <br />Gambling Site <br />Name of site where activity will take place <br />Vie NaT 1'441 - ,44/4) <br />Street , - City State Zip code <br />�� i %� red S% <br />(4- t4 <br />tMK -5 /, <br />Date(s) of / (5 9 <br />L. <br />Tunes of Games <br />0 <br />County <br />Gams <br />Yoe No <br />Bingo n n <br />Raffles fr ❑ <br />Paddlewheels ❑ ❑ <br />Ti boards ❑ ❑ <br />Pull -tabs ❑ ❑ <br />b. roar raegl <br />�zlxGttrar, It(ct <br />Financial Report' <br />NurIo! • <br />of Prizes <br />How will profit be used: ejLAA-o J_ Pistnbutor horn whom gambing pmern Puhcti 59d <br />I declare all information submitted to the Department of Gaming 1 dgclere aN f ifomtaWon submitted td the:! <br />is true, accurate, and complete 15 ttua, acxxrrate and compfete -- - -- <br />�r� 3 -023- 90 <br />f)hief Hxpnntive nffinsie cK irutahup 11atr i:hiwf azacuhva nf(ieef etenahtrn <br />tot tlerri[ng <br />yIi <br />Local Government Acknowledgement <br />I 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 government passes a resolution to specifically 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 />City or un ase <br />Township <br />Township name <br />Sign tur ✓f pe receiv lication <br />Signature of person receiving application <br />TideL,i /Gri »tilivti (� e receiv 9e) <br />Title <br />Date received <br />voile - Good <br />Pink - agwANi Mall this application and fee of $25 (check made out to Commissioner of Revenue) to: <br />Yellow- Boiled Mum* ded... lmb Department of Gamin - Gambling Control Division <br />complete *hided le «. P 9 5 <br />Gold - City aCounty Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />Page 61 <br />