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LG220 <br />(nev.1 viwo0) <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 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 />Organization Name / Current/previous license number Current/previous exempt number <br />,%� /ICK5 ��N1rinri r O X -4a09f - D-/ <br />Street City State Zip code County <br />02919 cSimps v$T Vase-oil e: ,V' 637,3 h4/y1sEr <br />executive tcer Phone 3E Treasurer /0/ K •^ r Phone G J j <br />/79,'4 fa, GKeoti) (41� )7-,i 7 / - •t_ (/>/) -91' -5/ ? .J <br />'type of Non profit Organization <br />Chief y <br />c �c lrn1 r� - <br />Check the box below which indicates your type of organization <br />❑ Fraternal ❑ Religious ❑ Veterans Other non-profit <br />Attach proof of nonprofit status which shows/ 74, _.ld <br />that your organization is nonprofit <br />❑ IRS designation i 3 " 22-6-y3 79? <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />ffiliate of parent nonprofit organization (charter) <br />Gamb[rn�t a$itc <br />Name of site where activity wilt take place <br />City Township <br />ow / .7 s/- ,2,r-.4E (t 14- <br />Date(s) of activity <br />N /i y 42, <br />Types a. f Carte <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />Smote Zip code <br />" .5.5//3 <br />C�o 9ty <br />Kelm sEV <br />-al -ya <br />F- inanciai Report <br />pansast 3nctudmg Nei profit <br />nl of:Rrizea !' .. <br />iarket;yalue :' <br />efPrizes ..: <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and complete. <br />CChief executive officer's signature« 74rd (4. red m, J CtiietexecutiYe otfioer' <br />Local oovernrnent Acknowledgement <br />Distributor fram'. <br />ng equipment w <br />purchased; <br />g:sirlbUtors license numtaer; <br />1 dscr araa1Finforrnanpnsw.bmrttedto the Gamb)ing;CantreI <br />(ft aCCbrw(a a'nd GOmpie(g <br />ignature <br />pate ". <br />1 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 Township <br />application <br />ate received <br />Township name <br />WkoIo oomd <br />Pink ....pgan ante, <br />YMlav -Buald mNm0 to O.ganizaoOn to <br />cOmplut. ellaOod uoas <br />OOId .... CIIy Or County <br />Signature of person receiving application <br />Title <br />Date received <br />Mail with $25 permit fee ar4 • <br />Department of Ga <br />Rosewoo Page 4 <br />1711 <br />Ho. <br />of nonprofit status to: <br />ontrol Division <br />Floor <br />