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(CG220 <br />(aev. 390) <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 Name <br />North Ramsey 500th Lions Club <br />Street City <br />0. 130)4 17031 Sr. Prfwi- em'Ssic7 <br />Chief executive officer Phone <br />oldrront/previous license number <br />None 1447497r— <br />State Zip code <br />Treasurer <br />Gregory NP11iP (6612) 429 4620 Raymond— Ha,Ls.,n <br />Type of Non-profit Organization <br />gemo•Uprevious exempt number <br />o62. <br />County <br />�u 'iri 4 z. v, <br />Phone <br />S14 4R4 -83A5 <br />Number of years in existence r 0 Number of active members (must be age 18 and older) <br />Check the box below which indicates your pe of organization <br />al Fraternal ❑ Religious ❑ Veterans ❑ Other non - profit <br />Attach proof of nonprofit status which shows that your organization has been nonprofit for the most recent three years <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 />Venetian Tnn <br />Street City or Township <br />9R14 Rine qt_, Little Canada <br />Q te(s) of i `1 3 <br />Typos of Games <br />Game <br />SMfifg <br />Bingo ❑ <br />Raffles <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs ❑ <br />State <br />MN <br />Zip code <br />5117 <br />County <br />Ramcey <br />Financial Rcpoz <br />t t?xpensss.tnetuding sat profit:: <br />Cailtof 6iftieiiXM _ ... <br />How will profit be used: <br />Biat.t/ 4.4 <br />Motor: <br />Of wnam:gam <br />................ . <br />................... <br />................... <br />ling )P <br />rased <br />................ <br />f till .Lcense.nimber <br />I declare all information submitted to the Gambling Control Division <br />is tru accurate, and complete <br /><gi1 <br />C <br />IrY "rt <br />•• - <br />ture <br />oil traatrom submrtted tp the geerWr gCont„e1:: �sw <br />ate, and comp1era <br />execu off rs s <br />Local <br />vernment Acknowledgement <br />Chief exacutwe officer& signature '; Date g <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Division and will become effective 30 <br />days from the date-of receipt by the city or county, unless the local government passes a resolution to specifically prohibit the activity. A copy <br />of that resolution must be received by the Gambling Control Division within 30 days of the date filled in below. Cities of the first Bass have 60 <br />days in which to disallow the activity. <br />City or County <br />Township <br />City or county name <br />trrru O\NAoPc <br />Township name <br />Sign of persgryfeceiving p�p ccaptlon <br />Title Date received <br /><� CJ o6 o -264 <br />vmro - Bard <br />Pink - aenu.ua, <br />Yellow- Bowd mee,ms to ag.n:ara m <br />compete shaded some <br />Gold - Glom Cony <br />Signature of person receiving application <br />Title <br />Date received <br />Mall to: <br />Department of Gaming - Gambling Control Division <br />Mail Station 3315 <br />St. Paul, MN 55146 -3315 Page 1 <br />