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Minnesota Lawful Gambling FOR BOARD USE ONLY
<br /> CHK
<br /> LGr2o Application for Authorization for NST DATE
<br /> T" " ' 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 Current/previous license number Current/previous exempt number
<br /> s st .Paul clown Club Inc. X-03908 7507922
<br /> Street City State Zip code County
<br /> 1124 N T,raxi ngtnn PKV fit Paul Mn 551 03 Pamsev
<br /> Chief Executive Officer Daytime Phone Number Treasurer Daytime Phone Number
<br /> ,yn_G Freiermuth ( 61h 489 3534 John Affeldt 612) 6310614
<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 /> ❑ Veterans it Certification of good standing from the Minnesota
<br /> ❑ Religious Secretary of State's office
<br /> X q 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 nr}sctv
<br /> -
<br /> Street City'` Township State Zip code County
<br /> 5394Fdgf wood Dr. Moundsview MN 55112 Ramsey
<br /> Date(s)of a vity(for raffles,Indicate the date of the drawing)
<br /> April 22/1994
<br /> Types of Games < • Financial Report Market value of Prtzes
<br /> Expenses,Including (Including:Donations
<br /> Game(s) Gross•Receipts= Cost:of Prizes Net Profit and:cash)
<br /> Bingo ❑ $ .22-a.ao $ 225: oa.
<br /> Raffles C
<br /> Paddlewheels ❑
<br /> Tipboards ❑
<br /> Pull-tabs G�
<br /> I declare all information submitted to the Distrbutor from whom gambling equipment was purchased
<br /> Gambling Control Board is true, accurate, Olaf butorslicense number
<br /> and complete.
<br /> I:declare-all-financial:information submitted to..the Gambling Control
<br /> Boardis true.accurate,:and complete
<br /> 4 i '0 - . .. „ . . ... . . ...... ..... ... .............. .. . ............... . ...
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<br /> Chief Executi e Officer's Signature Date Chief Executive:Officer's:Signature ,:Date
<br /> :l=ocal`U it of Government.Acknowedgment
<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 class have 60 days in which to disallow the activity.
<br /> City or County Township Township is
<br /> City of cob name Township name ❑organized
<br /> I ,r �r"..) ❑ unorganized'
<br /> Signature ..�receivi application Signature of person receiving application ❑ unincorporated*
<br /> �r - *Attach letter
<br /> Title' / Date receivedTitleTitle Date Received
<br /> le
<br /> t�///G* ;� i�I G l a-6 -{y�J
<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
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