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10220 Minnesota Lawful Gambling <br />(Re 11'14/90) Application for Exemption from <br />Lawful Gambling License <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 />V`arne dn4 Arldr' of O rg<nnization <br />Organization Name <br />$treat City I State <br />\j \—&c " CA=I1'Nna Qt] 1._. C.„ <br />Chief executive officer <br />urrenvprevious license number <br />;'ire af`�t'ar� <br />Phone i9 /+�C//' ` Treasurer <br />YG'�i7 ) . // <br />t Organization <br />Zip code <br />� <br />`1N 55I)� <br />Current'previous exempt number <br />L C'-1 .— 9 <br />County <br />(\�� <br />Phone li\ <br />(V00 -) A%-t- <br />Check the box below which indicates your type of organization <br />❑ Fraternal ❑ Religious ❑ Veterans S -Other non -profit <br />NiffUninglirtAt <br />............::::......::. <br />ame of site where activity will take place <br />y1 <br />� 5'c \�ti L \N <br />Street City <br />��\a �•C� <br />Date(s) of activity <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 />(71 Affiliate of parent nonprofit organization (charter) <br />Township <br />State Zip code <br />Nt),ia MN <br />County <br />�A (v�5 e <br />nrlriciaL oat <br />Game <br />fngtugfni <br />brtass: ??. <br />Bingo ❑ <br />Raffles <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs ❑ <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and com t#te. <br />Chief executive officer's signature Date <br />% at rverniitient Acknowledgement <br />DrsMbutor kit n wfiom yam P! <br />irikuri?i boa <br />00c/areelf itorniaotxllkltimittoct <br />t , acgGtafe, and complete <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 spedfically 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 Township <br />City or county name <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 />WNb- Board <br />Pink -- Organization <br />Yellow -Board reavne b c,gaazetion b <br />wnpere shaded seems <br />Gold —City on 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 Page 7 <br />1711 W. County Road B <br />Roseville. MN 55113 <br />