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,-' CG220 <br />(Rev. (am) <br />Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <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 Address of Organization <br />For Office Use Only <br />Organization //�� <br />Pose y/ 11:7, ceniOr- Y2renAS A5sr1 <br />_IILS ra rd V; eW A ✓P hJ leer-eV/III MN 6:57/S iQ <br />e execu v,/� Phone Menagx --, <br />'fan Type of Non-profit Organization <br />current/previous license number <br />Street City State Zip code <br />current/previous exempt number <br />X- 4.2 County 2/3— 0/ <br />ant <br />�✓ isoY&Y7, <br />Chief ti officer <br />(<ii� `iii --ji zS n nil. /z rnT,i <br />Years in existence 7 Attach proof of three-years or more of existence. Number of active members <br />❑ Fraternal ❑ Religious ❑ Veterans '4 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 />Name of site where activity will take place <br />i€s eviF Arex. 4%i(I,(.le 5c /o 6 <br />Street , ity State Zip code <br />[� iE„. cry 1 eiff /f �i�rvk mAi ���/,7 <br />Date(s) of activity <br />F; day , /%, -/) /92/ <br />Topes of Games <br />County <br />ct .c e <br />Gams Vas <br />131 go <br />Raffles <br />Paddlewheels ❑ 1SI <br />Tipboards ❑ tgi <br />Pull-tabs ❑ <br />How will profit be used: <br />El g <br />❑ lg <br />nancial op <br />prom <br />Co pt Prins <br />W ertz's <br />n.Wl�:e4u�3>Fl+.ert1 <br />i declare all information submitted to the Department of Gaming <br />is true, accurate, and complete <br />t infamahott; submdtad tx the Department of Gaming <br />are andoomplete <br />j:hief expcut(vp offiner's einnanvp nafp <br />P.htaft>vprhva nflrcpN aionnhtre* 1) <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 county name <br />Township <br />Township name <br />Signature of person receiving application <br />Signature of person receiving application <br />Title Date received <br />Title <br />Date received <br />r ewe Mall this application and fee of $25 (check made out to Commissioner of Revenue) to: <br />"k- -Board ni <br />vea.- eo.er.wn.ad' nag ,e Department of Gaming - Gambling Control Division <br />compleis Gold "GryaCounty Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />Page 38 <br />