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CG220 <br />(Rev. (8/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 />ev: I I t S'N;Ov <br />Street <br />6YS' //{riVc/ <br />la rem 7S Qss'l <br />City State Zip code <br />RoSr✓,`/1< I rN SSi l3 <br />Phone Manager <br />Chief executive officer <br />1-141, yi /e (3 /4,K{ (ea) P73-Ur/ <br />Type of Non-profit Organization <br />current/previous license number <br />t, o <br />current/previous exempt number <br />a'aa13 -S/ <br />Q County <br />l\ fs Phone <br />(hal. /T3 - 6/S'1 <br />Years in existence <br />❑ Fraternal <br />6 <br />Attach proof of three years or more of existence. Number of active members <br />❑ Religious ❑ Veterans a,Other non - profit <br />Go <br />If 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 k Affiliate of parent nonprofit organization (charter) <br />Gamblina Site <br />Name f site where activity will take place <br />o$ea /ic area, M,ca /c <br />Street City <br />/ S E. Co, ,C d . -� L <br />Date(s) of activity <br />1r, `4(1 Twt.tc <br />Tunes of Games <br />Sc DI <br />- rt l c SCay J.1 <br />Zip code <br />/CZ% SC /i3 <br />County <br />66MS, <br />Game <br />Raffles <br />Paddlewheels <br />Ti boards <br />Pull -tabs <br />How will profit be used: <br />Yee No <br />FutanGzal Report <br />Ores roe <br />Ong • <€ N t titgift <br />1 declare all information submitted to the Department of Gaming <br />is true, accurate, and complete <br />W e- a -a7- 90 <br />jlhinf prutive ntfirer'¢ ¢innahue Date <br />rsaNtnformati004ubmuted iantof darrnr <br />accuralo and cpmpleta <br />hie f aYOrit va A:ei5t ginnahit <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 govemment 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 cou ame <br />Township <br />Township name <br />Sig atu : of p97son reoei <br />ti <br />g application <br />Signature of person receiving application <br />"37 6C ea 4 <br />WNW Bowel Mall this <br />Bkk- GBNd:Wp <br />Yellow coma,.lxn."Gr -t n <br />Odd - City a Courtly <br />ate r ived <br />a o'7 96 <br />Tide <br />Date received <br />application and fee Of $25 (check made out to Commissioner of Revenue) t0: <br />Department of Gaming - Gambling Control Division <br />Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />Page 22 <br />