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hfinnesota Lawful Gambling <br />Application for Authorization for <br />Exemption from Lawful Gambling License <br />Fill in The unshaded patrons of Ibis applicaam for exampban and <br />sand it in of /out 45 dope before yourgambling acovltylorprocosang. <br />Name and Address of Organization <br />Organtalbn Name I Cunentpmoue lbsroe number I Cumrforsomexerrptnumber <br />n'•V St- Dg 1 `In 59+1fN Rnmc 12 IF <br />civil Eaeculhe Cllba Daylvn, Pborr Nunaer Treasurer Daylms Photo Number <br />�,f Freiermuth (61)l 489 3534 John rlffeldt 612) 6310614 <br />Type of Non-projrt Organization <br />(Check the boa that Indicates, your proof of nonprofit <br />Chock the box below which indicates your type of organization status and attach a copy of the proof to the application. <br />C Fraternal IRS designation <br />_ Veterans ( Certification of good standng from the Minnesota <br />Religious Secretary of Statel office <br />5 ( Othernomprafit Ir Affiliate of parenlnonprafitorganirabon(charter) <br />Gamblina Site <br />Name oI sae wnere a v ry roll lake pace <br />BIW,I clry••••••••••••••••Tormsrq sloe zV ads cauny <br />a1N _ _ _ _ _ i Ratti <br />Dale(a) Of Wyatt (for Mln, bdkafe the (111e of I <br />.;pril 22/1994 <br />Types of Games <br />camels) Gross <br />Bingo _— <br />Raffles <br />'inanctal Report <br />Including <br />Pdaa Nat Profit <br />Martel valve of Prise <br />(Including Donations <br />and cash) <br />.5 225.00 <br />Paddlewheels = L I <br />Tfpboards <br />Pull -tabs -x <br />1 declare all information submitted to the Oeflator IWm whom ganaaq equipment was Purchased <br />Gambling Control Board is true, accurate, 6utors license nemW, <br />and complete. <br />'Boom Is sue. accurate. and complete. <br />I <br />Cora EleaullW Officers signature Oats Chief Eaecullvo Omcers signature Date <br />Local Uitit of Government Acknowledgment <br />I nave received a copy of the appYWllon. The application viol Wrevewe0 by the Gamblag cantor goad and vial Wamaanearre 30 days it= the WAS of <br />recepl by the city or couray. unless IN WA uM of gavemnere passe a tnoWWn to speallcalr/ prohbl the ad". A copy of Ing refoWbn n be W elvel <br />by IW Gambeng Caarol Boam wahn 30 Nys of IW data tiled In W bw. Clln d IW Inl tlass hrva Ii0 OM b wtetlt to dsabw IW atlNey. <br />city or county Tairri Township is <br />city of a rums r To^rdndwhe Corganized <br />Idaf i c i unorganized' <br />s; to Warn application slgmlun at penon Starting appicaton i unincorporated' <br />'Attach leter <br />Tile <br />- a <br />v Dale Waned lips ode Received <br />ni <br />rl I b <br />rhis form will be made available <br />in alternative format (i.e. large <br />print. braille) upon request. <br />'b"rJ <br />Mail with $25 permit fee and copy 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 />White - Original <br />Yellow • Board returns to <br />Organization to complete <br />shaded areas <br />