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LG220 <br />(Rev. 4/'93) <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 />tVH nViaHu Ubt ONLT <br />FEE <br />'NIT <br />CHK <br />DATE <br />/ I <br />Organization Name <br />Street <br />Current/previous license number <br />Current/previous exempt number <br />1-1 t, ii_ <br />±l <br />4 , <br />City <br />L <br />State Zip code <br />,11 il; <br />County <br />Chief Executive Officer <br />Daytime Phone Number <br />Type of Non. -profit Organization <br />Treasurer <br />Daytime Phone Number <br />(,,) -J > (, <br />Check the box below which indicates your type of organization <br />❑ <br />Fraternal <br />❑ Veterans <br />❑ Religious <br />Q 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 />I Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />Name of site where activity will take place <br />LI.\t• l -Ci f 1( i(:(i 2)C. li( i I <br />Street i Ctty Township <br />r1V • l)\S';I!\ -\i1 ._ \f,C L( <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />t `ii`f`i <br />State <br />MN <br />Zip code <br />(/' <br />County <br />/- 1 /1 (-/< ('.. <br />Types of Games <br />Game(s) <br />roes Receipts'. <br />Financial Report <br />Expenses,lncluding <br />Cost of Prizes <br />Net profit <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 />>utor from whom gambling equipment was purchased "s <br />Oishiutors license number <br />7.. <br />i declare all financial information submitted to the Gambling Control «; <br />Board Is true, accurate, and complete. <br />Chief,Executive Officer's Signature Date <br />Local Unit of Government Acknowledgment <br />Chief Executive Officer's Signature <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 urdt of government passes a resolution to specifically 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 o1 the first dass have 60 days in which to disallow the activity. <br />City or County <br />Township <br />City of county name ^� <br />SIgnature gpers 4 receiving Jajpplic(aC"(7 Jf 1.4 <br />Tale <br />This form will be made available <br />in alternative format (i.e. large <br />print, braille) upon request. <br />Township name <br />Signature of person receiving application <br />Date received Title <br />fee and copy with $25 permit 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 />Date 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 />