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LG220 <br />a" "r'"g°` Minesota Lawful <br />Application for <br />a Exemption from <br />Lawful Gambling License <br />Fid rn the unshaded pomons of this application for exemption and send it in at least 45 days before your gambling activity for processing. <br />........... <br />ame <xnrt Ad ireess of Orgaierzattorx;' <br />amazon re _. _.. <br />Currenvprewous license number Currenvprevwus exempt number <br />FEE <br />INIT <br />FOR BOARD USE ONLY <br />CHK <br />DATE <br />ID EAGLE 71Ret /955 <br />5 1 ti E 6.41 -D F/1-.61 QoG, stare ip code Cbun <br />e c. IE1Hy - BC -r?7d. L/-�K� of �(J $�3 /JO /-4-74/517;" <br />Chief executive officer / <br />^� _ rv� ��I J_ (Phone) _ T ^assurer klae _ / Phone <br />K LP ( /0!L did? <br />�e of `,rli'a►t profit tyrgunizatcan <br />Check the box below which indicates your type of organization <br />❑ Fraternal C Religious ❑ Veterans <br />Oambl tt Sate. <br />Name of site where activity will take place <br />yz r /iW a-'t,' �T; <br />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 />O Affiliate of parent nonprofit organization (charter) <br />[ t <br />ST if City �/ gd wn hip <br />Date(s) of activity ,cept y 2. 3 q ' <br />,`tjpes of Games „ <br />Game <br />Bingo <br />Raffles <br />State <br />MN <br />ZIP code <br />5 S //3 <br />County <br />Gross receipts <br />iitnanczat Report <br />EYpeaseetlncwdfng Netprofit .....:: starker Value} <br />Cost of pr2as .... of Raise <br />Paddlewheels <br />Tipboards_ <br />Pull -tabs <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and complete. <br />Dsi.1m9r4om whom gambling cto .em <br />as ptraiase <br />f declare aff infomistic r sutirnrtted Ja the ::Gambbng Cprytrol <br />lS hue, accurate, and comprate: .. ... <br />Chief executive officer's signature Date Chiefexecutiveoffken's signature: : <br />Local Government Ackreowtedgement <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 speafically 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 />City or County <br />Oa <br />City op coon <br />o <br />Township <br />Signatt)r'e of y rson re. -�ng application <br />Titl le' ��// 6 Date received <br />LLfCr�G <br />Township name <br />Mite -Bowl <br />Pink - 'Organism <br />Yellen -Savo returns a Oros/tampon to <br />OMnplMs tntded Mee* <br />CoM —City M County <br />w <br />Mail with $25 permit <br />Department <br />Ro <br />Signature of person receiving application <br />Page 1 rrofit status to: <br />inuoUVllle. MIN bbl IJ <br />sion <br />Date received <br />