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LG220 <br />(nevi 1 /1a/9%) <br />Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <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 />erne an ganiz n;: <br />Organization Name Currentiprevious license number CurrenVprevious exempt number <br />R'L 4 sscyc oF7-EnvSegYof MAI 1/l- iqY;'/c() <br />greet City State Zip code County <br />3G�ao W, 'i sT 4,vy 5LMtN /t�jf ss93/ N,�NNefrld <br />C hief azecutive o(flcer Phone Treasurer Phone <br />mat IM) (4ia f 4R8Fig1 i Rea< (bit) gas --9977 <br />►e <br />ligOliONNit0404101 <br />Check the box below which indicates your type of organization <br />❑ Fraternal ❑ Religious ❑ Veterans Other non - profit <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />❑ IRS designation <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />Name of site where activity will take place <br />ably &CE .5t. tau Nivk A <br />Strom N T City <br />V �/VEt�A <br />De6°?od" bigg/ <br />2t pas of athes <br />.......................... .................:............. <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />Township <br />MN <br />SS/LS <br />Zip code <br />ounty <br />A-M SE y <br />Financial Reporti <br />Isincluding Netprafft <br />et prtzas ... .. <br />Aad(81 valueaes <br />l declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and co p plate. <br />Af l✓a j'r <br />rf executive officer signature Date <br />4,zgiifairMWMWWWiyMWiRJMMWMMW <br />nt <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Division 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 Gambling Control Division 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 />Township <br />Township name <br />Dwtnbutot &license number <br />1 deciaro a1f lnkfrmaaoa submrtted <br />istruer - Grata <br />Ch f executive aH(ceissignsiure :: <br />City or County <br />City or county name <br />Sig attar- ofperson wing app{ on <br />T <br />WNIe — Board <br />Pink — -0rgonizadcn <br />Tenors —Board returns to Organization to <br />complete shaded areas <br />Gold —City or County <br />Mri�with $25 permit fee and copy of proof of nonprofit status to: <br />/, Department of Gaming - Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B Page 35 <br />Roseville. MN 55113 <br />Date received <br />Signature of person receiving application <br />Title <br />Date received <br />