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MINN6';OT/1 UI:.PARfM7-i0r or tf n.NGL <br />GAMING DIVISION <br />Mr)i.1 Station 331S <br />St. Paul MN 55146 -3315 <br />LAWFUL GAMBLING EXEMPTION <br />FOR BOARD USE ONLY <br />INSTRUCTIONS: 1. Submit request for exemption at least ®D 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 he 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 />UN ?Co <br />Number of Members <br />As <br />License Num er (if currently or previously <br />licensed) n /or permit number. <br />oI f IC N5[,_.n <br />Address <br />1772._-c• &77+ AVE 1ki0 <br />CI <br />� � ^1 & T/+ <br />State <br />°fv <br />Zip <br />S7 7 <br />Co My <br />t iC ti 1 t rC =; <br />Chief Executwe Officer's Name <br />STcvc ill 1kh1tInc( <br />Phone Number <br />)Ltd3`i73-C,twG <br />Manager's Name <br />pen c L� 1ilei;I o. <br />Phone Number <br />( C;)2) y�C(.-5'4 <br />Type of Organization <br />❑ Fraternal ❑ Veterans <br />❑ Religion 'Other Nonprofit Organization <br />Attach proof of three years existence <br />If Other Nonprofit Organization (Check One and attach proof of nonprofit status). <br />❑ IRS Designation <br />op Incorporate with Secretary of State <br />(Affiliate of Parent Nonprofit Organization <br />Name of Premises Where Activity Will Occur <br />Betels) of Activity, Drawing(s) <br />Premises Address <br />27—Li 1. 3 k-(cc <br />`-- <br />City <br />uTTC C c tUrVir <br />State <br />/?2t ' <br />Zip <br />557 7 <br />Cp6,04 <br />r- P-fvr se 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 />/\ <br />X <br />f <br />0,000 O17 <br />61GY90.©0 <br />oil , 0 <br />icOOG. to o <br />Paddlewheels <br />Tipboards <br />Pull -Tabs <br />Use of Profit <br />ri(P PPoeternll fry ST, a-1uc 4 SU U1.13S <br />Distributor From Whom Gambling Equipment Acquired �([t <br />kJ( <br />Distributor's License No <br />I affirm all information submitted to the Board is true, <br />accurate, and complete. <br />Chief Exeytftive Officer Signature <br />C44. -nF,.e i95,-1 <br />Date <br />I affirm all financial information submitted to the Board is true, <br />accurate, and mpl te. <br />i <br />Chief Err Ccutive Officer Signature <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 been served with notice that this <br />application will be reviewed by the charitable Gambling Control Board and will become effective Q,days 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 within §O days of the below noted date. <br />�c <br />CITY OR COUNTY TOWNSHIP <br />Name of Local Governing Body (City or County) <br />Cr /. i / 1/2 K q,vi OF/ <br />*Gee of Person Receiving plicatio <br />CG- 00026-02 (8/88) <br />Township Name (Must be notified when County is the approving body) <br />Signature of Person Receiving Application <br />"14 r /i,., /, <br />Date Received <br />/s /9 <br />Title Date Received <br />White — Board <br />Pink — Organization <br />Page 16 <br />s to Organization to complete shaded areas. <br />