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LG220 <br />(Rev. 4/293) <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 betors your gambling activity for processing. <br />Name and Address of Organization <br />Organization Name <br />North Sllhlirhan Evening 1 inns <br />stree1977 matilda StreOe Roseville Nsia)5113 zit cade <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />f- <br />CurrenUhrevlous license number <br />Current/previous exempt number <br />X- 04193 -94 -001 <br />county <br />amsey <br />Chief Executive Officer <br />Loren A. Hanson <br />Daytime Phone Number Treasurer Daytime Phone Number <br />(61 372 3331 mark Sundq tst ( ) 290 -3433 <br />Type of Non-profit Organization <br />Check the box below which indicates your type of organization <br />❑ Fraternal _ <br />❑ Veterans <br />❑ Religious <br />® Other non -profit <br />Gatnbiing Site <br />Name of site 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 On file <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />Ea AffiliateQof patent nonprofit organization (charter) <br />Street City Township <br />2 814 Rice Street Little Canaa <br />State <br />MN <br />Zrlp code <br />55113 <br />County <br />Ramsey <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />Matt 21, 1995 <br />Types of Games Financial Report <br />Expanses, including <br />Gamo(s) s Gross Receipts °r Cost of Prizes <br />Net Profit <br />Market Value of -Pdzas <br />(Including Donations <br />and cash) <br />Bingo <br />Raffles <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs ❑ <br />1 declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />declare all .financial Information submmed to the Gambling Control <br />Board tatnre;accurate, and complete. <br />Chief Executive Orators Signature Data <br />Chief Executive Officers Signature <br />Local Unit of Government Acknowledgment <br />I have received a copy of this application. This application w ti 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 specfflcaly prohibit the activity. A copy of that resolution must be received <br />by the Gambling Control Board within 30 days of the date Tilled In below. Cities of the first Bass have 60 days kt whkh to disallow the activity. <br />City or County <br />Township <br />City of county name <br />Signaturg of person receivi, app cation <br />a l <br />Title <br />This form will be made available <br />in alternative format (Le. large <br />print, braille) upon request. <br />Township name <br />Signature of person receding application <br />Date received <br />Title <br />/- 9 -95 <br />Mail with S25 permit fee and copy of <br />proof of nonprofit status to: <br />Gambling Control Board <br />1711 W. County Rd. B, Ste. 300 S. <br />Roseville, MN 55113 <br />Page 114 <br />Dale Received <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 />