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Minnesota Lawful Gambling <br />Application for Authorization for <br />GeV "gal Exemption from Lawful Gambling License <br />Fill in the unshaded portions of this application for exemption and <br />send R in at least 45 days before your gambling activity for processing. <br />Name and Address of Organization <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />f_ / <br />aNzatlon Name I <br />cACAS tl l / /r nn; -14 ±E ?ocj <br />Current/previous license number <br />6Qr'`ict -r) 1 <br />Street Chi State Zip code <br />Current/brevlous exempt nunber <br />95 J mice . 774 Pett41 mn� 6-51i <br />Chief Executive (Sheer Daytkne Phone Number / i / Treasurer <br />Type of Non-profit Organization': <br />e,/t.nTErcaennTh <br />Co ty <br />Daytime Phone Nun-ter <br />(61221S,11,f._3' <br />Check the box below which indicates your type of organization <br />❑ Fraternal <br />❑ Veterans <br />❑ Religious <br />ea Other non -profit <br />Gambling Site <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 />-CZ Affiliate of parent nonprofit organization (charter) <br />Name 1 site where activity will lake place <br />Vszk� Q -�, -rn n <br />Street J, (� (City J� Townsk p State Zlp code <br />.� % R 4 ice L - /-i'/ ci:nft . 01 MN -S'S <br />y i e 17 o 5 /9 /at--, <br />Financial Report <br />Expanses, including <br />Cost of Nth** Net Profit <br />Date(s) of activity (for raffles, indicate the date of the drawing) / <br />Types of Games <br />Games) r'. Gross Receipts <br />Flaunty <br />el CA xv 1' <br />fAadut Value of Prizes <br />(Induding Donations _. <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 />7lstrbulor iron whom gamblkg equipment• was purchased. <br />Dtsubutofs license number. <br />tdeclare all financial Irtormatbnsubnttted to. the Gambling Control <br />Board is true, accurate, and complete. <br />Chief olive • dicer's Signature Date Chief Executive Officer's Signature <br />Local Unit of Government Acknowledgment <br />I have received a copy of this application. This application wit be reviewed by the Gan-tiling Control Board and will become effective 30 days from the dale of <br />receipt by the city or county, unless the local unit of government passes a resolution to specifically prohbt the adlvfty. A copy of that resolution must be received <br />by the Gambling Control Board within 30 days of the date liked In below. Cities of the first Bass have 60 days in which to disallow the activity. <br />Camay or Coounty <br />Cly oL-� ylNVt.( <br />Township <br />Township name <br />Signature •I pars • receivi <br />Title <br />application <br />Signature of person receMng appkcatbn <br />Dale received <br />This form will be made available <br />in alternative format (i.e. large <br />print, braille) upon request. <br />Title Date Received <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 19 <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 />