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• <br /> minnesoca 1..2WJur. ciambting FOR BOARD USE ONLY <br /> • LG220Application for Authorization for FEE CNK <br /> INIT DATE <br /> (Roy.4/2/93) <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 /> Organization Name North Suburban Chapter/ CurrenUprevtous license number Current previous exempt number <br /> Minnesota Deer Hunters Association G 336 <br /> Street City State Zip code County <br /> 11516 Utah Ave . No. Champlin MN 55'116 HPnnPnin <br /> Chief Executive Officer Daytime Phone Number Treasurer Daytime PFione Number <br /> Mark Almquist €12) 421-1495 Joseph Langevin 612) 434-0580 <br /> :;Type of Non-profit Organization <br /> Check the box that indicates your proof of nonprofit <br /> Check the box below which indicates your type of organization status and attach a copy of the proof to the application. <br /> ❑ Fraternal ❑ IRS designation <br /> 0 Veterans ❑ Certification of good standing from the Minnesota <br /> 0 Religious <br /> ® Other non-profit ® Affiliate of parent nonpfit organization(charter) <br /> Gamblin Site <br /> Name of site where activity will take place <br /> Bel-Rae Ballroom <br /> StreetCny twr State <br /> 5394 Edgewood Dr Mounds . IAN 1 2 County <br /> Date(s)of activity(for raffles,indicate the date of the drawing) 11 1 Ram y <br /> December 4, 1995 <br /> ;.Types of Games <br /> Fltrzancz <br /> al>3teport <br /> Expenses,Fncludng (Including uDonation. <br /> Gams(s) GrossReceipts <. Cost of Prfzas :.Nst Profit < <br /> ❑ <br /> and cash) <br /> Bingo <br /> Raffles - <br /> Paddlewheels 0 <br /> Tipboards 0 <br /> Pull-tabs ❑ <br /> I declare all information submitted to the bistrbutocfrom whom gambling equipment was purchased: <br /> utr�sucensen <br /> Gambling Control Board is true, accurate, Dlstooumber•: <br /> and complete. <br /> declare:all tinanclal information submitted to the Gambling conird <br /> Boardtrue accurate and complete >. <br /> ,.:,::::...;::,-,::.ii...:.::,,:::::::::::,..::::::::,:::::.:::,:.:::.;.:.::-,:.::.:::::::::::::::::::::::;;;:::::-:,;:::::;:.:,::::.:.::::....,;.,:::"..:.::.,:.:..;;;:;.:.;;;.:...:;.i.;.i,.:....::;....:::;::,..:...;.::.:::::::,z.i_::....:.:...:::::.,:.:..: <br /> fl)Z/ d � <br /> Executive Officer' ignaturs Date 'Chief Executive Otflcar's Signature --- <br /> ,/ Local Unit.:.of Gov ernment•Acknowledgment :: <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 /> receVt 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 <br /> by the Gambling Control Board within 30 days of the date filled In below. Cities of the first class have 60 days In which to disallow the activity. <br /> City or County Townshl _ <br /> Cm' name Township name Township is <br /> Oa,J; ❑organized <br /> gnature o "=rson recei ng .f%in Signature of person recehring application/0-,-) ❑ unorganized' <br /> �' ❑ unincorporated' <br /> / *Attach letter <br /> file <br /> Date received Title Date Received <br /> C/4//dd '4/Ce 7 all s - <br /> This form will be made available Mail with $25 permit fee and copy of White-Original <br /> in alternative format(i.e. large proof of nonprofit status to: Yellow-Board returns to <br /> print, braille) upon request. Gambling Control Board Organization to complete <br /> 1711 W.County Rd. B, Ste.300 S. shaded areas <br /> Roseville, MN 55113 <br />