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LG220 Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />(Rov.11 /14/90) <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 />mime adAddes f Ogai xaio <br />Organization n <br />Name <br />DUCKS uivzi/v7irev <br />Street City <br />07955— 4 / Cxe S os.efJ/L/. <br />Chief exaculive pfficer Phone Treasurer <br />Current/previous license number <br />x 62°79- a/ <br />Zip code <br />State <br />/ - /ti4 ,s. (Gila) .,/Y'y A53/ <br />e f Nort4proeit Organization <br />Check the box below which indicates your type of or aniz ion <br />0 Fraternal El Religious ❑ Veterans Other non - profit <br />Current/previous exempt number <br />SD /‘,,3 <br />County / <br />Phone At�se` y <br />( ) <br />Gwnbftrii Site <br />Name of site where ctivity will take place <br />2/ 714en4/v _ ice,) <br />Street _7/e/ 7y c; Township State <br />OC% � /l' <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit 3 �. p <br />❑ IRS designation / 3 --3 5i / <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />Affiliate of parent nonprofit organization (charter) <br />Date(s) of activity <br />n des <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />owns ip <br />.C,TIZ/" C/1/711/,,9N <br />Zip code <br />?Aim 5€1/ <br />A/-070-95 <br />I declare all information submitted to the <br />Gambling Control Division is rue, accurate, <br />and complete. f //4 coo -Ca <br />sirtbu.or sl>cense nl <br />the GamBfribi ancol <br />Chief executive officer's signature Date <br />!tr#teit Acknoitvledgemertf <br />signature Date <br />Glib l <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 <br />City or un�ty ame <br />.f (l �> ( / / (�/X� <br />ignatyfe of p; rson recei�� a licahon <br />Township <br />Township name <br />Till <br />WNIe - Board <br />HM-- dgm¢0EOn <br />Tallow -Board retina to agoriraeon to <br />compere shaded aeoa <br />Gold —Gry or County <br />Signature of person receiving application <br />ate received <br />Title <br />/ -8- 93 <br />Mall 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 <br />1711 W. County Road B <br />Rncovillo kAN cci 1 fl <br />Date received <br />Page 6 <br />