01/23/1995 Council Packet - Laserfiche WebLink

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LG220 (Rev. 4/2/93) Minnesota Lawful Gambling Application for Authorization for Exemption from Lawful Gambling License Fill in the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing. Name and Address of Organization FOR BOARD USE ONLY FEE CHK INIT DATE Organization Name 57. To .5 A P9/2t6'1 Street City Current/previous license number State Zip code 17i E/,,, S;:z L,/11h Chief Executive Officer Daytime Phone Number Treasurer J of f ; izt4 %gy X0/5 Roft Type ofNon-profit Organization Current/previous exempt number County Daytime Phone Number Check the box below which indicates your type of organization Fratemal Veterans Religious ❑ Other non-profit Gambling Site Check the box that indicates your proof of nonprofit status and attach a copy of the proof to the application. ❑ IRS designation kr Certification of good standing from the Minnesota Secretary of State's office ❑ Affiliate of parent nonprofit organization (charter) Name of site where activity will take place R,.6ti ,4// Street City / Township Date(s) of activity (tor raffles, indicate the date of the drawing) Types of Games Game(s) Gross Receipts State MN Z'p code 1 (-) / County .j1 a /( Financial Report Expenses, Including Cost of Prizes Net Profit Market Value of Prizes (including Donations and cash) Bingo Raffles ❑ Paddlewheels ❑ Tipboards ❑ Pull -tabs ❑ declare all information submitted to the Gambling Control Board is true, accurate, and complete. 'Distributor from whom gambling equipment was purchased Dish tutor's license number /4!Y ,N 1 declare all financial information submitted to the Gambling Control Board is true, accurate, and complete. C t Executive O s Signature Date Chief Executive Officer's Signature Date al Unit overnment Acknowledgment 1 have received a copy of this application. This application wiU be reviewed by the Gambling Control Board and will become effective 30 days from the date of receipt by the city or county, unless the local unit of government passes a resolution to specifically prohibit the activity. A copy of that resolution must be received by the Gambling Control Board wlthin 30 days of the date filled In below. Cities of the first Bass have 60 days in which to disallow the activity. City or County C 1 county name Signature VI pcation Title ved �ys Township Township name Signature of person receiving application Title Date Received This form will be made available in alternative format (i.e. large print, braille) upon request. Mail with $25 permit fee and copy of proof of nonprofit status to: Gambling Control Board 1711 W. County Rd. B, Ste. 300 S. Roseville, MN 55113 Township is ❑ organized ❑ unorganized* ❑ unincorporated' Attach letter White - Original Yellow - Board returns to Organization to complete shaded areas