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LG220 <br />(Rev. 4/2/63) <br />Minnesota Lawful Gambling <br />Application for Authorization for <br />Exemption from Lawful Gambling License <br />Fill in the unshaded portions of this application for exemption and <br />send it in at least 45 days before your gambling activity for processing. <br />Name and Address of Organization <br />Organization N <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />f <br />f <br />Cument/prevlous license number <br />Cpnantip !eylpua sump omber <br />County `t 6 y 6 <br />Street <br />Chief Executive Off <br />•,ayllme Phone umber Treasur <br />//YO) <br />Type of 'on -profit a ganization <br />Daytime Phone umber <br />Check the box below which indicates your type of organization <br />❑ Fraternal <br />❑ Veterans <br />❑ Religious <br />gOther non -profit <br />Gambling Site <br />Name of site where divity will take place <br />0—titt a n _7:1✓7 <br />Street City strl <br />Townp <br />/ <br />Date(s) of activity (for raffles, fficlicate the date of the drawing) <br />Oc 4 At, e 3 /79:3 <br />Types of Games <br />Check the box that indicates your proof of nonprofit <br />status and attach a copy of the proof to the application. <br />❑ IRS designation <br />Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />Games) <br />Bingo <br />Raffles <br />State <br />MN <br />Zip code <br />5// 3 <br />County <br />Ramsey <br />Financial .Report <br />Expenses, Including <br />Gross Receipts Cost of Prizes <br />Net Profit <br />Market Value of Prizes <br />(Including Donations <br />V <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Puri -tabs ❑ <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />71stribmorirom whom gambling equipment, <br />as purchased. <br />DIdrbuto <br />license number.: <br />%y <br />1 declare all financial information subndtted to the Gambling Control: <br />Board Is lrue.accurate, and complete. <br />Chief Executive Officer's SlgnaturV Date <br />Chief Executive Officer's: Signature <br />Date <br />Local Unit of Government Acknowledgment <br />1 have received a copy of this application. This application will be reviewed by the Gambling Control Board and will become effective 30 days from the date of <br />receipt by the city or county, unless the local unit of government paecac a resolution to specifically prohibit the activity. A copy of tha resolution must be received <br />by the Gambling Control Board within 30 days of the date filled In below. Cities of the first dass have 60 days in which to disallow the activity. <br />City or County <br />Township <br />Sig <tury'of pergon receiv <br />Title <br />This form will be made available <br />in alternative tormat (i.e. large <br />print, braille) upon request. <br />Township name <br />Signature of person receiving application <br />Title <br />7 /ai /93 <br />Mail with $25 permit fee and copy of <br />proof of nonprofit status to: <br />(',ambling Control Board <br />1711 W. County Rd. B, Ste. 300 S. <br />Roseville, MN 55113 <br />Page 90 <br />Date Recanted <br />Township is <br />❑ organized <br />❑ unorganized` <br />❑ unincorporated* <br />* Attach letter <br />White - Original <br />Yellow - Board returns to <br />Organization to complete <br />shaded areas <br />