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CG2 <br />Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />For Office Use Only <br />All in the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing. <br />ame and Address of Organization <br />Tit) C.>Fttt &7 ar ME A5Soc/47za ' <br />Street CI State Zip code <br />�Zltl �, &t/) EAELEBLJQ, l3Hfir &A-R, /�jiv. $3ric <br />of a eCU� oNlcer � Phone Manager <br />currenvprevious license number <br />2111 <br />Type of Non-profit Organization <br />current/previous exempt number <br />&-tom z - 9 -236.0 <br />Years in existence Attach proof of three -years or more of existence. Number of active members /S <br />❑ Fraternal ❑ Religious ❑ Veterans Other non - profit <br />H you checked box for other nonprofit, check one of the following and attach proof of nonprofit status <br />❑ IRS designation ❑ Incorporated with Secretary of State ❑ Affiliate of parent nonprofit organization (charter) <br />Gambling Site <br />Name of site where activity will take place l //�- 2c 5 m, cMA f 7'- <br />Street nfc& 5.77 Lo /c g c + Stan <br />5r a //3 <br />Date(s) of activity <br />Se 2-3, 19 9 <br />Tunes of Gaines <br />/27}14t15- <br />•I 1$ ! xp•i San <br />Raffles _� ■ <br />Paddlewheels ❑ ❑ <br />Ti.boards ❑ ❑ <br />Pull -tabs ❑ ❑ <br />How will ee�of it be used: <br />`f , j'4y' f R tyPeuiSts n5sicf 7zo <br />ation submittekf to the Department of Gaming <br />nd • •mplete <br />Chief p nrutivn nffirpr a sinnahrrp <br />Date <br />fmm whPrrigamWing9 !iutpmencpttrcts4t':' <br />moor ef;Ga' ng <br />htnf t tPrilfia nfiv nrFA slpnahtra i`i4 <br />F}A <br />Local Government Acknowledgement <br />1 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 />Township <br />City or unty n <br />Sig a r. of pp on rece n f.pplication <br />f / 41, i <br />/ <br />Title <br />Township name <br />Signature of person receiving application <br />receivS Title <br />-2=261-9d <br />Date received <br />vmb- Bow d <br />n,k- ay.xxwon Mall thls application and fee of $25 (check made out to Commissioner of Revenue) to: <br />V.dw - ewd uums b Otgwtzake b <br />wnp.bw.e.dmom Department of Gaming - Gambling Control Division <br />Gold -City 'County Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />PAGE 86A <br />