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LG220 <br />(Ray.11114/90) <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 />Kane and Address +, f IOrganization'. <br />Or•- ization ame <br />Currenvprevious license numbe <br />Current/previous exempt number <br />tree - C' State Zip code Coun <br />hief executiv fficer I Phone Treasure ) hone <br />U ;\�t (P (�.IG� ilia' US LC"CYI_c.:�iCtiVf4( (oX z '�t`i- ��{< <br />glipe of orootitotto G1rartiza €ion!: <br />Check the box below which indicates your type of organization <br />D Fraternal ❑ Religious ❑ Veterans 41 -Other non - profit <br />Garnblinct Site <br />N me of site where w <br />activi i f take place <br />Y(wick i &L Jv-y` <br />S ar' j+ " 'C '7 <br />D re <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />❑ IRS designation <br />;Certification Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charte <br />al;\�tiviry 9_3 \Go <br />toes Gaines <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />Township <br />State <br />MN <br />Zip code <br />-, -.- 3 <br />County <br />Finanetal Report <br />ros's recafpts .iFF..apertsesr intiiitdtng Net ptafiE <br />' Cost et hrtzes ' <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />a d comp -tfe. <br />................... <br />................... <br />p'stnbi for <br />•-ftt om gamblarcg equipment was purcryased., <br />ptsutWor's license numbs <br />1 ;d t/ rq ae fnttinnaeort sub rrtttecf 7o tlte;Gamblitig Qppfr& <br />'S';(rue, accurate and compigte . <br />Ph l execu ve offl is signature Date <br />t Goie meat Acknowledgement <br />Chief executive officer's signature <br />Date'; <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 />Township <br />��uZ -ct�v <br />gnyature'ot person recejyinQ application <br />Title, <br />1'?° -G li_. 7. <br />white— eovd <br />Mrk — - Crgmizalon <br />YeCon --Board reams to Organization to <br />compete shaded mom <br />Gold - -- City or County <br />Township name <br />r1-- <br />Date received <br />Signature of person receiving application <br />-- / -f $ <br />Title <br />Date received <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 <br />1711 W. County Road B Page 4 <br />Roseville. MN 55113 <br />