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LG220 Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />(Rev.11114190) <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 />Name and Addre t a, j" Organ anon l <br />Organization Name <br />D cX5 U`li ti f-ed v..rno ;ll CL <br />Street City <br />2 ?LI u. teas�o.P 2o<a.o :rte <br />Current/previous license number <br />X— L2. -01 <br />Zip core <br />s.�ff_' <br />State <br />N <br />Current/previous exempt number <br />50i 63 <br />Chief executive officer Phone Treasurer <br />Rr <br />Nfl rC +Jt1 <br />'Type of " i'on - ro, it O rganization: <br />County <br />falit <br />(Pone (74�)`av7 -,5308 <br />h <br />(r3 /Cc <br />Check the box below which indicates your type of organization <br />❑ Fraternal 0 Religious ❑ Veterans %Other non - profit <br />Gambling site <br />Name of site where activity will take place <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />❑ Ins designation <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />Affiliate of parent nonprofit organization (charter) <br />V ev\ <br />Street <br />ZEIL Sk.t.na-I- <br />Date(s) of activity <br />+t'tv\ <br />City <br />1 ' f le <br />Apr1i IS, I'jI <br />Ty'of Games <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />Township <br />Cis vt is lil4. <br />State <br />MN <br />Zip code <br />5cIt.3 <br />County <br />ktx.ltista <br />Report " <br />Net ptoft Market Valusl; <br />ol.Pdmes <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and" mplete <br />r • <br />D sinbutor from who <br />en twas pci:0 sad! <br />suibufid. icense ti rise <br />It i rt:S h_ <br />a�clareaff ..i�+tdrmaeorr. sUbmttWdto ilia <br />accurate and completo <br />ftfcers signature <br />a <br />et executive officer's signature Date <br />wear Government Acknowtedgeote t <br />Ctife <br />to ?coffee <br />amMeg Cpttffnl <br />Date <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 />City or County <br />City or•sun amt. <br />i11,41 t7✓ �4, <br />application <br />Township <br />Township name <br />Signature of person receiving application <br />Tl / il�7` �e7 <br />ived Title <br />Mali 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 <br />Roseville. MN 55113 Page 6 <br />white - Board <br />Pink - - C,gmrtodm <br />YdIo -Boed rerun. to Organization to <br />complete shaded seas <br />Gold City a County <br />Date received <br />