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@6t07/994 14r38 <br />Z b124266444 RRITZ MPahlUSOI1 <br />LG22ep <br />{R.v. 4rae3i <br />Minnesota Lawful Gambling <br />Application for Authorization for <br />Exemption from Lawful Qbiing License <br />Fri, all fro unshaded portions of Ode lgtpHasfien for toomption and <br />sonic If m at toast u dais balm put gpi ilirrNaptiviy. brprocessinQ. <br />Name and Addr-eris q' anizaaltfot: <br />Organlu lion Name <br />Children' s Hosptwa_1 of St Paul <br />Street City <br />345 N. Smith Ay'. St- Paul <br />Chlei Executive Officer Daytime Phone Humber <br />Brrck Nelson (61) 229-6110 <br />Type ofNan=prgfit Organization <br />Gurrrnt4xwbus license number <br />X-62164-93 <br />Biala Zb code <br />Treasurer55102 <br />Hen Dawkins <br />FOR BOARD USE ONLY <br />FEE CHK <br />INJT DATE <br />Currentlprevious siterript nurmer <br />62098 • <br />County <br />Ramsey <br />Daytime Phone Nuke". <br />(61) 349-5226 <br />Chock the box below which Indicates your type of organisation <br />❑ Fraternal <br />0 Veterans <br />n Religious <br />I Other nonpproft <br />Gambling Site <br />Named site whin a[lhdty v41 take piece <br />Gem Lake Bill& Golf Course <br />Street Totwohu <br />4039 Scheuneman Rd. Gem Lake <br />Dale(s) of activity (for relies, indicate the date of Me drawing) <br />July 9, 1994 <br />Types of Gashes <br />Game(*) Grose Receipt. <br />Bingo <br />Check the box that Indicates your proof of nonprofit <br />status and attach a copy of the proof to the applioalion. <br />❑ IRS designation <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />Affiliate Parent niynprofit orgenitabon (charter) <br />Stale <br />MN <br />.Financial Report <br />Pipettes., Inolumng <br />cost of Prises <br />Nei Profit <br />County <br />Market Vela* of Prins <br />(Including Donations <br />and caoh) <br />Baffles <br />Paddlewheels <br />Tipboards ❑ <br />Pull -tabs ❑ <br />1 declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />Dist►dtuior from whom gambling equipment was psirchas <br />tisinbulorl license number <br />PI- <br />7�__ <br />144 <br />Chief Executive Officers Signature ate <br />Local Unit of Government Acknowledgment <br />I declare all financial information submitted to the Gambling Control <br />BwNd i1 hue, ■courate, and complete. <br />Grief Execrative Dterers Signature <br />i have receives a copy of Ibis application. This application wtq be reviewed by the Gambling Control Board and will become elleaive 30 days Irom the dale el receipt by the city or county, unless the Iocil undi of government passes a resolution to apsadfketll y prohibe the activity. A copy of that resolution must be reoetved <br />by the Gambling Conlroi Board within 30 days of the dale filled In below. pities of the Int lass have 60 days in which to disallow the actkviry. <br />City or County Township <br />City of courtly name <br />� gel Lot <br />Signature r ra..., ... . cation <br />Title F• G /*1 n Q <br />s <br />C . ]r /-' <br />This form will be made available <br />in afterna,ire format (i.e. large <br />print, braille) upon request. <br />Dale received <br />Township ream <br />Signature a:person raceMng application <br />Ails <br />all ith S2E permit fee end 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 />Township is <br />❑ organi#ed <br />❑ unorganized* <br />❑ unincorporated' <br />* Attach utter <br />Date Received <br />White - Origina`I <br />Yellow . Board returns to <br />Organization to complete <br />shaded areas <br />