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LG220 <br />(Rev.11 /14/90) <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 />Arne a td Address of organization <br />Organization Name Current/previous license number Current/previous exempt number <br />eh Lo 6%(g 41D+ /9- 550 c, Al6A2 8- 91-001 41/- 11/60760 <br />Street Chy State Zip code County <br />52/ 4 r� d,4CD Ert-GLC BC1.D, ,HT C tEE /9 /. $37/o /It7'ISS ' <br />executive o icer Phone Treasurer / Phone <br />AciP-{ L1 Ls Y lr (Gl2— (v 35 -%?? NICfl V/ht) �Kc /t caoZ) 42.q -.5390 <br />e of iron pr# s Or url izat on <br />Check the box below which indicates your type of org i ation <br />❑ Fraternal ❑ Religious ❑ Veterans Other non - profit <br />Gambfln# Site <br />Name of site where cti will take place n <br />VA) E. 17 4,) /LESMU,r ,q// <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />❑ IRS designation <br />6ertification of good standing from the Minnesota <br />,Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />2.St et City Township <br />tg /q 2iC,:5f / 5-01/ <br />Date(s) of activity 5— ry—r—r 2 q <br />O <br />00$101190#01:111:;:11 <br />—t' L < <br />Game <br />Bingo ❑ <br />Raffles X_ <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs ❑ <br />State Zip code <br />MN 5o//3 <br />ounry g�-� <br />(MSt. f <br />BAIL <br />Financial Report <br />Expenses, tncfuding Net profit <br />Cast ot:Prizee <br />Yalu <br />299? <br />amblln egu'pment <br />purciased: <br />I declare all information submitted to the <br />...ntrol Diyis' n is true, accurate, <br />dg4lom 1rfarmanort sirbmrttadtatheGdtnbfingQannpl <br />.., acpura9, andcomplere .. <br />Chief executive officer's signaturrb Date <br />Local Gorrerrtrtrent Acknowledgement <br />Chief executil <br />EHwers sig attire; <br />.................... <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 />City or County Township <br />City or unty name <br />Signal of arson r 'ving application <br />Date received <br />Township name <br />Signature of person receiving application <br />�A. <br />8 ,3 -j.9. <br />Title <br />Date received <br />WNW- Board <br />MMC - - Organization <br />YSio, -Board teaxns to Organization to <br />comets shaded woos <br />Gold — City of 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 3 <br />1711 W. County Road B <br />Roseville. MN 55113 <br />