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Re os ss Minnesota Lawful Gambling For Board Use Only <br /> Fee Paid <br /> Application forAuthorization for an <br /> Exemption from Lawful Gambling License Check # <br /> Initals <br /> Date Recd <br /> Organization Information <br /> Organization Nam Previous lawful gambling exemption number <br /> Street City State Zip Code County <br /> 7UfS'7 �OrFi'CJ �C -rk� G till =rC✓;L ,� r lP✓ _33 - 3 A" - KPc <br /> Name of Chief Executive Officer of organization (CEO) Daytime Phone number of CEO <br /> First Name Last Name <br /> f ev <br /> 2 I 6,l-t 1, ? 'T. W , CI- ((ice) N ��l'- �1 � 7 <br /> N ame of rganization Treasurer <br /> First Name Last Name Daytime Phone Number of Treasurer <br /> 6 ce/ <br /> Type ofNonprogt Organization <br /> Check the box below which best describes Check the box that indicates the type of proof attached to this application <br /> your organization by your organization: <br /> 0 IRS letter indicating income tax exempt status <br /> 0 Fraternal <br /> [� Veterans 0 Certificate of good standing from the Minnesota Secretary of States office <br /> ( Religious E3 A charter showing you're an affiliate of a parent nonprofit organization <br /> Q Other nonprofit Proof previously submitted and on file with the Gambling Control Board <br /> Gambling Premises Information <br /> Name of Establishment where gambling activity will be conducted <br /> quaL./ - f J 57 �tL �; '' E4�G <br /> Street City State Zip Code County <br /> 765 CCCrrt�cClj (ZDR -D LJ i- 1 Ili 53 /k� - +� <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> Ar' /Z IL- '-si /CKr <br /> Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> F 'Bingo Co Raffles F 'Padd(ewheels [:] 'Pull -tabs () 'Tipboards <br /> *Equipment for these activities must be obtained from a licensed distributor <br /> le sure the Local Unit of Government and the CEO of your organization sign For Board Use Only <br /> the reverse side of this application. Date & Initials of Specialist <br />