02-13-1991 Council Agenda - Laserfiche WebLink

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LG22o Minnesota Lawful Gambling Application for Exemption from Lawful Gambling License (Rev.i1114/90) FOR BOARD USE ONLY FEE CHK INIT DATE Fill in the unshaded portions of this application for exemption and send it in at least 45 days be /ore your gambling activity for processing. Name 'and Addriess of Organ ization .4 ryanization Name /A /D .LotKc>.s- ,Z1 oN5 Current/previous license number Current/previous exempt number X— 0)..0 EA-07 Street . City State Zip code L(/ / /38'Tli A0-C NE Za e IN 5 5 3 o 3 Phone Treasurer :1 s# e5 Ll tit rr4sToy-t (lvf2-) ?f-od5S? Roa0 cyKC90-7(i (Glz) 7& -/283 tae of Nort profit Organization Chief executive officer County 4v a Phone Check the box below which indicates your type of organization Fraternal ❑ Religious ❑ Veterans ❑ Other non - profit GumbLLnfl tS"tite Name of site where activity will take place Attach proof of nonprofit status which shows that your organization is nonprofit ❑ IRS designation ❑ Certification of good standing from the Minnesota Secretary of State's office ❑ Affiliate of parent nonprofit organization (charter) ,z /, / 99/ Street City /� 777—C Too wnship/7 State PA )C.tCE J 1l .& IJO�.7a MN t thi Date(s) of activity , / / _ 9. 1 Zip code Cony Ka aey des of fart Game Bingo Raffles Paddlewheels ❑ Tipboards ❑ Pull -tabs ❑ inaneia .............. .............. panes including.',: Cost etPriaes I declare all information submitted to the Gambling Control Division is true, accurate, and omelet wv let a wive officer's s!nature Date erntnent Acknowledgement iibutor from whom gambling equiRmeat was purchased Dfst iNpoti *Nose.num5:er I d&area/l fritm,ation submlKad to the Gamb)ing'Contlp� s mien acraate, andcompletp PM? cutIve officer's sfgnetura'. Date I have rece ved a copy of this application. This application will be reviewed by the Gambling Control Division and will become effective 30 days from to of receipt by the city or county, unless the local government passes a resolu ion to specifically prohibit the activity. A copy of that resolution must be received by the Gambling Control Division within 30 days of the date tilled in below. Cities of the first class have 60 days in which to disallow the activity. City or County City or unty aeme Signature Ti f pers n receiv application Lai-- received rc�/t GGa 02-6 -f/ Township Township name Signature of person receiving application Title Date received while - Board Pink - - O.ganizoem esteem -Board returns 0 organization 0 compete shaded areas Gay _.. City or Come Mail with $25 permit fee and copy of proof of nonprofit status to: Department of Gaming - Gambling Control Division Rosewood Plaza South, 3rd Floor 1711 W. County Road B Page 6 Roseville. MN 55113