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LG220 <br />(Rev. 4293) <br />Minnesota Latoful 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 actnny for processing. <br />Name and Address of Organization <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />Organization Name <br />Duck- ow) M /TEQ 0!0 <br />Currenbprevbus license number <br />do.r a9 -o l <br />Cunenprevlous exempt number <br />Street , / •-�-� State Zip code <br />5 <br />on-3 /y 1) / Zr Z astro/LLat 44w SS //3 <br />Chef Exec tive Officer Daytime Phone Number Treasurer <br />At/ K/ a/Ilir (lea) 31,11- ets3c1 <br />Coun <br />AMl $t V <br />Daytime Phone Number <br />( ) <br />Type of Nonprofit Organization <br />Check the box below which indicates your type of organization <br />❑ Fratemal <br />❑ Veterans <br />Religious <br />non-profit <br />Other <br />Gambling Site <br />Name of sae where adlvlty will take place <br />/44 Inn 7744/ <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 /,3 ^,�/o y3 % 97 <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />S Pi'S/ c 1 s, m Jmzt K v <br />State <br />MN 4142 <br />Zip code <br />.SS //3 <br />Date(s) of activity (for raffles, hdfcate the date of the drawing) <br />Types of Games <br />Game(s) .Gross Receipts <br />Financial Report <br />Expanses, including <br />Cost of Prizsa <br />Net Prod <br />Market Value of Prizes <br />(Including Donations <br />and cash) <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 />7istrbutor from whom gantisg equipment was purchased <br />1.-lbutors license number. <br />1,-64 ate/,e414/t) <br />declare all financial irdormatlon submitted to the Gambling Control <br />Board is True, accurate, and complete. <br />L.i//af 15 <br />Chief Executive Officers Signature Date Chief Executive Officer's Signature <br />Local Unit of Government Acknowledgment, <br />1 have received a copy of Ihis application. This application wla be reviewed by the Gambling Control Board and will become efiective 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 that resolution rnust be revewed <br />by the Gambling Control Board within 30 days of the date filled In below. Cafes of the first dass have 60 days in which to disallow the activity. <br />City or County <br />Townshlp <br />City of county fnarne Township name <br />Ignature o personrceivingyplication <br />Title / r ate received <br />4 'AT.// 7c d77 - t / —R-9/ <br />This form will be made available Mail with $25 permit fee and copy of <br />in alternative format (i.e. large proof of nonprofit status to: <br />print, braille) upon request. Gambling Control Board <br />1711 W. County Rd. B, Ste. 300 S. <br />Roseville, MN 55113 <br />Signature of person receiving application <br />Title Date Received <br />Page 95 <br />i <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 />