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1..G220. A k, Application for Authorization for INIT DATE
<br /> (Rev.4221M) ,
<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 Addi-ess:Of OrganizatiOitE: :: ::::::::-.-E---rE-- -.::----, ______ / /
<br /> Organization Name North Suburban Chapter/ Current/previous license number Currerd/previous exempt number
<br /> Minnesota Dr Hunters Association
<br /> Street City State Zip code County
<br /> 11516 Utah Ave. No. Champlin MN 55316 Hennepin
<br /> Chief Executive Officerillpytirne Phone Number Treasurer Daytime Phone Number
<br /> Mark Almquist 421-1495 Joseph Langevin 12 ) 434-0580
<br /> .7ypei:of Non-profit Organization .E-.::-.-,::E.:::::EgE.:,-...--- E .,- •E E :!.:. E:::--„:.:E-.EEE_E-.::::,.:::. :E:.:.:z-:. .:::..-::._-.-:„:„:„.„-::„-:::.::.::-.-,:.:.-..., -: ..:. -:...„.„.:.:--:-- . --...
<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 /> El Fraternal 0 IRS designation
<br /> 0 Veterans 0 Certification of good standing from the Minnesota
<br /> 0 Religious _ Secretary of States office
<br /> Ej Other non-profit g Affiliate of parent nonprofit organization(charter) - _
<br /> 'G antbling...Site.1'E::.-.-E::',E'E ':-. -:: " -E- -':.-:E:::- •::•:,• -..,,E'E
<br /> Name of site where activity will take place
<br /> Bel-Rae Ballroom
<br /> Street City Township State Zip code County
<br /> 5394 Edgewood Drive Moundsview MN 55112 Ramsey
<br /> Date(s)of activity(for raffles,indicate the date of the drawing)
<br /> August 25, 1995
<br /> y.... Type -t•faames-::. ::::::-,:E.--:.]:-. :EE.E.:E. -:-:--E-:Eii::-!-EE,:::::;:-::-1E::::E=:i::::-E' :]-:.i.:i,:-.:...::i:- :•: 0,..-:Financt'al;-Eggport: ErE-.-0:::-::::...:;E:E;E: ;E::-...Ei-E:::::-E::::.
<br /> Market Value.Of Prizes?':'••
<br /> -:.,.:.-:?:,-.:::,-:1-:'::: ::-:•i'::::::,.::.--::-?:-•::::::.-:.:-:Expentee;Including,n. lis::::::,...c,: :::::::::E: i-i,::'-:::-:.::i,::::]::::.:,.::::.,,,.:::.:::::':.,,,:M-:(IncitidIng Donatione .
<br /> Game(s) :•':-]:.:':::iGtolut ReceiPtit-:::-.::: ::::-,:::::.::':U::-:-:-Cost of PrizesV-:::::::.: :::'::::::::: :;;',.i:::::i:::::::•,::Net.Proflt:: :.::in:: :::-::ii:,:.:),:i:]-::::::.i:.::.,and ceshY,I.:::iiiii:;-'!'.-::::::i,::::',:
<br /> Bingo CI '.,::',.-:-...,::-::'-::!;:.:-,-::::':-:-.::,:::.**.--i1::-,:i--. 1,:iF::::.,:.:'.::: :::-.:: ::::-.-1.,::::_u::::.A:es::::-..;,pi„--.':':::,-.T.;:-.-..:::::.: :::::g::::i.:,::::•::::::]:':: : ::.-:::.,:'.:::: ::_.:,: :.:::;::- ::',.i*,.„„:.:.;::-,:::::::,..:A„,--'-i::i-:: .„,.:----:..
<br /> Raffles
<br /> Paddlewheels
<br /> Tipboards CI
<br /> Pull-tabs El
<br /> I declare all information submitted to the .Distrbutor.from whom pstg.:ding:equipmeffiwas purcil.a.sedo ::,,n :!::.:i....:: ::::„..:
<br /> :::::--::,:!:::.*:i*i:i..,:..:::-:•,:::,::.i:_,::::-:„-::-...:::&.:.:,..::i.::::,,„::::...,.,:-._::,::.::,...f.::.,-?.,.„::.:,.-.:.„:::-,:::::.:::::.::.:.:..:::::::,..T.....r.:.:..._,....._....... ...
<br /> ci Gambling Control Board is true, accurate, pistioutoroiqensepumbe .: ::.;:i:, .i..:.-:::::-:i::i-,.:.:A:::,:.:::.,::.,::::::.::.:x„,:::::?::-,: :::::.::::--,.: :,:-::,_-,
<br /> / and complete.
<br /> I declare aglinancial infomiation:submitted to the Gambling Control i:.:::::.::•::.:::,:-.- :::-:::
<br /> Boardistrue;:accuraterid coinplete.::::]:1: .:1:";:-!'ci:: ::::!:,::::.-::.1:: :E.:,,.::::::';.:: ::.:::::::::,.::::-.:::J:
<br /> .-:,--:: ]]::,:] ,-:.„.:-::::,,,::::,:,_:,:-.-.:::.,:i:.:: s,:,:0:-:,::::: ::::::. -:..-iii::.: z::-::.:-..:.:-.-:.::i.:: ::::,.:,:: ::;::::.,:::.:.:.::: :..: .::•:-;-...,-..::-:.::,_.::,::-:-.-: .
<br /> Chief Executive Officer's Signature Date !Chief Executive Officer's Signature -. -: , :-.:.'Clate..-.'
<br /> ..k Local Unit of Government Acknowledgment..-E:-EEEE--.--:-.-.',--E-E-i-:--E_E-:-,:._E_E-EE.E'-----:::.-::.'E.:E.'EE-E E E.--E':-.--E---E,-EEEE-'.E-E:_:::.:EE--'..E-.:E-'-i:E•E'C'E-:-:-E;E:...:-El:.EEEE.:-E EE-:-.-i-EE.:--EE:':::.:----:-:.--E-.:-:'::::: E- EE'.::::---'---:-...-""E: .. -- E -:--
<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 unit of government passes a resolution to sped-lice/1y 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(Jess have 60 days in which to disallow the activity.
<br /> City or County Township
<br /> Township is
<br /> ,
<br /> City of y u name Township name
<br /> El organized
<br /> /ido;i' --)
<br /> SI nature. •, on rete . -..licat
<br /> City
<br /> Signature of person receiving application 0 unorganized*
<br /> It, 0 unincorporated*
<br /> ....-,,,,.„, .Attach letter
<br /> Title Date received Title Date Received
<br /> s •
<br /> c
<br /> This form will be made available Mail with$25 permit fee and copy of White-Original
<br /> ___,
<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. IS, Ste.300 S. shaded areas
<br /> Roseville, MN 55113
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