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LG220 < r <br />(Ravi/1100) <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 117 the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing. <br />en)zauon Nams <br />a _1Y..T LJC �...i•1N�li n+ C�, \ fl t, rlr.) `�J)A 3:, <br />Street City <br />Chief executive officec Phone Treasurer <br />\ v..%\C \--\\\t\ :w,NN (1 v'a.) l,A _ ,..i fl(<. Q.ta;b <br />of iati�awa}ic e1444440C <br />Check the box below which indicates your type of organization <br />o Fraternal ❑ Religious ❑ Veterans Vel Other non - profit <br />Currenvprevious license number <br />Currentlprevious exempt numbe <br />( <br />County <br />Phone <br />State <br />11-nagli Site <br />Name of site where activity will take place <br />Zip code <br />I i i. \I <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 />Street _ <br />Date(s) of actiWty <br />City Township <br />•:\C.E. \_ -- -•.s- \.\ \�`,.\ <br />State <br />MN <br />Zip code <br />County <br />Game <br />Bingo ❑ <br />Raffles (%1 <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 />Chief executive officer's signature Date <br />al ;;Gover ment Acknowledgement; <br />psidbutorfrain whom gambling equtpmentwas pu chased:: <br />Dtatributors'censenu er <br />:t CeE7,1r6dkinioYmOffR3( smrtt9dfo 10. GBtnbfjtt9 Godtrtri <br />:gyepP :MOM <br />Chia :executWe ofivors signature tlatf <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 />Clty or County <br />City or county name <br />Township <br />Township name <br />Signature of person receiving application <br />/Title <br />Signature of person receiving application <br />Date received <br />Title Date received <br />Mite - 9oord <br />Pink -- Orgmhndu, <br />Yellow -Saud returns to Orgon zadon to <br />complete shaded areas <br />Gold- -city or County <br />Mail 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 10 <br />Roseville. MN 55113 <br />