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CG220 <br />(Rev. ( &B9) <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 />2i /v.o ke s L i s Ct --C.c & <br />Street City <br />re93 Xe wr /7/ l levt es <br />curreneprevious license number <br />State Zip code <br />Chef executive a cer Phone Manager <br />� %�• hie/i4 et) 719%77'/ %%lilt t / /e-be /,ter <br />curreneprevious exempt number <br />2 County <br />/lA..€t& <br />Phone <br />(6/l f7 -3- "1 c/9 <br />Type of Non-profit Organization <br />Years in existence <br />f2'Fraternal <br />15 <br />Attach proof of three -years or more of existence. Number of active members <br />❑ Religious ❑ Veterans ❑ Other non - profit <br />,73 <br />H 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 <br />tiro tilt " n JA H <br />street S/`/ <br />�Cii -ty State Zip code <br />L.% Mull ((v /rode? /l.e-' <br />Date(s) of activity <br />9 9 <br />County <br />8/- set' <br />Tulles of Games <br />Gams <br />Bingo ❑ (-1 <br />Raffles <br />Paddlewheels ❑ ❑ <br />Tipboards ❑ ❑ <br />Pull -tabs ❑ ❑ <br />ritk.44041E.Aeport <br />:xpenese' In fudtng tM prolft <br />Ces1.QAP(lyros .. <br />U.ow will profit be used: <br />Ufib /7 1J,rh f0be >T- net./ am- 1.7e-if <br />flhap tw-' c 5 / r1 fe4 /6/ S <br />1 declare all information submitted to the Department of Gaming <br />is true, accurate, and complete <br />716( 4 2 -/- <br />• <br />cam whom gambling equipment flu. <br />atilt attaf tilibettae faun <br />k totmatkxt submutad <br />ate. and cantata" <br />the t epastawnt <br />% hief executive officer's sinnahve <br />Date <br />Chief axes ihiin nHiraNs kinnat( rr <br />Dafa <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 />Ci nr <br />unty name <br />Si .�TTrj. ofs.n r � g application <br />ar <br />Township <br />Township name <br />Signature of person receiving application <br />Date received <br />2— ? -90 <br />Title <br />Date received <br />NN%. - Baud <br />Pink - ag.g.w., Mall this application and fee of $25 (check made out to Commissioner of Revenue) to: <br />',Wow - Bard ,..„ns le agenbelon b <br />Gold CAN am* *'boded.«. Department of Gaming - Gambling Control Division <br />Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />Page 57 <br />