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FOR BOARD USE ONLY FEE CHK LG220 Minnesota Lawful Gambling INIT DATE (fla".11/1490) Application 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. `iii:.;;:,i : . .: '. .: `: ::::::::::::::::: ::'::: ` ::ii::::::::::::r: :y:::::::'€:€:::::::€:::y:::i: :::€:`:::€ is:::i :::i : :ti;:.'`:::::::Y: €:::;niii:::: Organization Name North Suburban Chapter/ Current/previous license number Current/previous exempt number Minnesota Deer Hunters Association Street City State Zip code County 8005 Groveland Road Moundsview MN 55112 Ramsey Chief executive officer Phone Treasurer Phone L . Jerry Blanchard iG12 ) 784-2206 Joseph Langevin ( 61 646-4319 Attach proof of nonprofit status which shows Check the box below which indicates your type of organization that your organization is nonprofit ❑ Fraternal _ CI Religious ❑ Veterans C3cOther non-profit ❑ IRS designation 0 Certification of good standing from the Minnesota Secretary of State's office R Affiliate of parent nonprofit organization (charter) ditifitiliii;:>::::>::<.;�:>;:::::?:x::?:::i::;::::s;::i::}<:;::::;::?:�::::::i:::::::;;i:::;:::::i;:ir:ii<:::>::>::::::;:;.:::#:<:�::::::::::::::::::i:;::::;: :i::::::::::::ii:::::Ez:`:?::i:::;::[:::::::>:::::`:�:: : :::::::::::: :::€:i::::€:::::::::>?::::::::::i :: #: :: :: ::i�� t `::::: >::::<> filigliiiii :::`iiti::::: >><:: :::::::>=>::::: ::<s::::: :::llii: :::::::>:i<::::>:iii i:<::::::::::iiii:»>::iii;:;::>:>:i::<::::::::s::>:<:<::`:j :::>:>::::::::::»»::>;::;>:>:y::>;`: Name of site where activity will take place BP rRe Rat 1 roam Street City Township State Zip code County 5394 Edgewood Drive Moundsview MN 55112 Ramsey Date(s)of activity . a a . ;:�:;":::....:>...:>y... :.:�::: ;:.:.;:a:..:�;.:.>::>::::.:::>::>::::i:.;:i�>:.;::>:: ;::»::>:::::::>:>: :;:.> s ;.i:ii:::ii:;i:�ii;.i;:ii:>.::::i'i::i:.:::.::�;::»;:::::.:>:.::.::.:::»::>:;::.>:.:::::>:>>:� :�:.::::<:::.:<.>:i�i i ::.;:.i i:•ii::;•:;;:i::>: y: <i:_%';ii: i:i�::::::i:::<: i# i;:i;:i:::::: £::::;:::::::::ii:::i::::::::::::::fii:: i::ii::3i;:;::;;:::ii:::iiiii::i:::::::::::::::::ii;::ii:::#:ir:::iiii :::::::i::i::;::iii::r::::i::i::;:: ;:iii;::;.:i;: i;:i;::;:;:£::is:t:::: :::::::: ::i::i::: :>..:... :i :. >W.:..:.::...............................................................:..::::.:::::::::::::.:::::.::::::::::::::::.�::::::::::;•:.::.::.:.:::.::.>::::.:;:;::.;:.;:.;:.>:::<:.>:.:::;.:::.::.;:::.>:.::•;:;.::viii;:i;:i:i::i::::iii i:::i .�:.........................:.:::<.::.;:.>:.:;.::.>::.:::::;:._:::.:::;.::_::::':' ::: :: ::: : : ::::::::i:::.::;::::::::i;.:;:?2:::::>::::i;::::;;:i::::<:: :::::i;::::: :3:i :i::i:::::i:ii:::::i::::ii ::::::i `::: :::i: ::`::i::::;:i:;:i;::: :;iiiii :•;;;,::;:•;:•;r.•:•;::•;kili;•;:•;:.:.:::.::iijlii:iiii ::::iiii :::::c::::x•:;•xa:•`.•::•,: . . •. . , ttoy .yam y...�t�+�Y.',.`j' 31:... 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I declare all information submitted to the €€s€€€€>:>t i#ribii itot's>l cei o nu e.:.::::::::.: ::::.:::..:::. ::::::::. ::::;:::::::::::::.:::::::. GamblingControl IDivision is true, accurate, '� and complete. ...,.E•"::::::::::i�::::::::5:::::: ::::i;:;::::::::::;;::;:;:;:;:'€::;';::: :::i::::.: D '?::::IIII::ir::i sisi:;';.:.:':::::::;':::i�:::;:;:;:::::::i<::::::::;:`: :€: ;+IIID':`IIIIIIII 5:'::`€i'''':::::I::::''::::IIIII.III 6 f ) 111Yf ' ! ..> .. i:;;:::i Q ate i:::ii;:iiiii::: cer's signature ate :_:isCfttefxect�{t :eiEitce :sst ntt +i:::ii::::::>::>::>::::>:::::i::i»:»::::>::::i:...:.........:....::::::::. Chief e utiv 9 ; .:::.:.: :::::::: < :•:::.::.:.:<. :•::•::::::.:::: •>:::.:;:.:::...: ................:.:............... :e:::i.::`en »:i>:iii i>::�::':' '•< > i'€€€€ € i is€€:: ::€::'•>€ '.: >:i€ €i€>i::>s::>zii€€€:`€ z''•iiii iiimi iiim :€:>::>':>:` > < :? iii::iii:i::i::i:Y:: i:.:::i:i::i :::•;•:�:.::.::.r:.t::;•::�:.;>;:.;:;.::::.::.::.;>:.::.;:<.>:.:;.:.::.::.;:.:;.. ;: i is..; ::>•::• :::i:. ;:::.>•: :;:..:;:.,.:i::i: ....................................................... I have received a copy of this application.This application will be reviewed by the Gambling Control Division and will become effective 30 days from the date of receipt by the city or county,unless the local government passes a resolution to specifically prohibit the activity.A copy of that resolution must be received by the Gambling Control Division within 30 days of the date filled in below.Cities of the first class have 60 days in which to disallow the activity. City or County . Township City or unty name Township name i o 5,- f/G� Signatureceiving a lication Signature of person receiving application i Ti'e Date received Title Date received r,-ha d-F r:.5L/c -.2y- 9 3 White–Board Mail with $25 permit fee and copy of proof of nonprofit status to: Ark--a9.,Qatlo, Department of Gaming -Gambling Control Division Yellow–Board OOrganizationOrganizationm completeshaded area. Rosewood Plaza South,3rd Floor Gold—City.County 1711 W. County Road B Roseville. MN 55113