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LG220 <br />(Rev. 4/2/03) <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 Name <br />North Suburban Evening Lions Club <br />Street City Slate Zip code <br />2776 Iona Circle Roseville Minnesota 55113 <br />Chief Executive Officer Daytime Phone Number Treasurer <br />Jerry Hess (612) 483 -0781 Mark Sundquist <br />Type of <br />Cunentprevious license number <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />/ / <br />CurrenUprevious exempt number <br />County <br />Ramsey <br />Daytime Phone Number <br />(612) 426 -5869 <br />Check the box below which indicates your type of organization <br />❑ Fratemal <br />❑ Veterans <br />❑ Religious <br />® Other non-profit <br />Gambling Site <br />Name of she where activity will take place <br />Venetian Inn <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 />' /z/ /)t c e Sfoeet 4,>9� P4 /1141t <br />Dale(s) of activity (for raffles, indicate the date of the drawing) <br />May 22, 1994 <br />State <br />MN <br />Zip code <br />yrounly <br />Types of Games <br />Game(s) <br />Bingo ❑ <br />Raffles <br />Paddlewheels ❑ <br />Tipboards <br />Pull -tabs ❑ <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />Financial Report <br />Expenses, including <br />Cost ot Prizes <br />Net Profit -; <br />Markat Value of Pdzn <br />(Including Donations <br />Ist tutor from whom gambling equipmert was. purchased <br />/11 <br />'Qmis z'% <br />utors ersenum <br />1declare all financial Informatlonsubmitted to the Gambling Cont <br />Board Is true, accurate; and complete. <br />let Executive Officer's Signature Date <br />Local Unit of Government Acknowledgment <br />Chief Executive Officer's Signature <br />Dale <br />I 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 passes a resolution to specifically prohibit the adivlty. A copy of tha resolution must be received <br />by the Gambling Control Board within 30 days of the date tilled in below. Cities of the first class have 60 days In which to disallow the activity. <br />City or County <br />Townshlp <br />City of unt- tyy fw''ne <br />Slgnaturry of ppeerr9on recent Lapplication <br />Title <br />t7k)-4 <br />This form will be made available <br />in alternative format (i.e. large <br />print, braille) upon request. <br />Towrshlp name <br />Signature of person receiving application <br />Date mceNed <br />/ /,R3 <br />Title Date Received <br />Mail with $25 permit fee and copy of <br />proof of nonprofit status to: <br />Gambling Control Board <br />1711 W. County Rd. 8, Ste. 300 S. <br />Roseville, MN 55113 <br />Page 7 <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 />