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Minnesota Lawful Gambling FOR BOARD USE ONLY <br /> FEE CHK <br /> LG220 Application for Authorization for NIT DATE <br /> (Rev. <br /> ` 4/2i93' 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: / I <br /> Organization Name North Sububran ` Current/previous license number Current/previous exempt number <br /> Minnesota Deer Hunters Association <br /> ity <br /> 8974 Quinwood Ln Maple Grove Me 4A)5°2A9 gentNepin <br /> Chief Executive Officer Daytime Phone Number Treasurer (aytime� 4o4 On*ej <br /> Carol Altrichter ( 614 420-8947 Joe Langevin l <br /> Typeof 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 - Secretary of State's office <br /> Other non-profit ❑ Affiliate of parent nonprofit organization(charter) <br /> Gambling Site '' . <br /> Name of site where activity will take place <br /> Bel'rae Ballroom • <br /> Street CityT State Zip code County <br /> 5394 Edgewood Dr Moundsvil wnship lMN 55112 Ramsey <br /> Date(s)of activity(for rattles,indicate the date of the drawing) S/Z C`g <br /> Types of Games Financr.al Report <br /> market Value of Prizes <br /> Expenses,Including (Including.Donations <br /> Game(s) Gross Receipts:' Cost of Prizes Net Profit .and:cash) :_ : <br /> Bingo ❑ <br /> Raffles <br /> Paddlewheels ❑ <br /> Tipboards ❑ <br /> Pull-tabs ❑ <br /> I declare all information submitted to the Distrbutor from whom gamblkig eq°lp►ner>i Was purchased <br /> Gambling Control Board is true, accurate, Distributor'slicense number <br /> and complete. <br /> I declare all financial information submitted to the Gambling Control_ <br /> Board is true,accurate,:andcomplete: <br /> —‘a_,-0 L 4 At T -t__!L 1-L--t— .,., /// <br /> Chief Executive Officer's Signature Date Chief Executive Officer's Signature - -`Date . <br /> Local-Unit of Government 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 /> 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 <br /> by the Gambling Control Board within 30 days of the date filled In below. Cities of the first Bass have 60 days in which to disallow the activity. <br /> City or County Township Township is <br /> City of county name • Township name <br /> 0 organized <br /> �e 0 unorganized' <br /> Signature y.o• -wing appli ion Signature of person receiving application ❑ unincorporated* <br /> /�/�V *Attach letter <br /> ` e Date received Title Date Received <br /> CH-i�,,� c? �4CC s--,—9 V . <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 />