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CG220 Minnesota Lawful Gambling <br />(Rev. twee) Application for Exemption from <br />Lawful Gambling License <br />Fill in the unshaded portions of this application for exemption and send it in at /east 45 days before your gambling activity for processing. <br />Name and Address of Organization <br />For Office Use Only <br />anizaaon currenuprevious license number <br />t^f4 £h c/ &1rTh ess Club, me . <br />Street n City State Zip code <br />f-D 6 °K /70i4 Sf. tart, Mil/ j- J'i/`7 <br />Ch executive officer - / Phone Manager <br />n.r?pr.,ae kasrebr-i- (r•tei 4( 90 -061 Jat�fei rNyPIMUtin <br />Type of No -profit Organization (r <br />current/previious exempt number <br />— � "2-010 3 --o 3 <br />County <br />_, { / <br />Phol,er r/ <br />(city 2i9 —x-373 <br />Years in existence Attach proof of three -years or more of existence. Number of active members <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 />73 <br />Name,ofrg whprg.p ity will t e place __. ' / <br />StreetO R c2 7/city t imItaecn4.2ihz esj' // <br />Date(s) of ©vityT 2_O / 6? 9, / <br />G' � <br />Times of Games <br />Tip —CoNuntg <br />Gem. <br />Yes No <br />Bingo n 17 <br />Raffles ❑ ❑ <br />Paddlewheels ❑ ❑ <br />Tipboards ❑ ❑ <br />Pull -tabs ❑ ❑ <br />How will profit be used: <br />Nd. in X19 -rea.. /�ci c1//dr s <br />Cu :� 4rt <br />ont m N' V PV-10 <br />rzancial Report <br />Nut grant <br />cg3gt Print <br />• ot Pan* <br />dare all info nation submitted to the Department of Gaming <br />is true, accurate, and complete <br />rfhot Pxrrnfive nffi r' Gi nature flare / .: ah3af rarfihvanffmw's *signahtr� <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 unty name�,q <br />Township <br />Township name <br />Signa 7of pers•n receiv .application <br />Signature of person receiving application <br />Title <br />Date received <br />QeQrw�;�:. C( 7;23 -91 <br />Title <br />Date received <br />WNW - Boyd <br />Pink - ag.wxam Mail this application and fee of $25 (check made out to Commissioner of Revenue) t0: <br />deteSlabaQ.nbabnb Department of Gaming - Gambling Control Division p.w.n.dwuw. <br />Bold - cyor County Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />