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For BoEdu Only <br /> a�s�res Minnesota Lawful Gambling Fee Paid <br /> Application for Authorization for an Check# <br /> Exemption from Lawful Gambling License Inftals <br /> Date Recd <br /> Otlpnization In formation Organ¢ation Name Previous lewiul gambling exemption number <br /> Evangelical Lutheran Good Samaritan Soviet X-04758 <br /> Stroet City state Zip Code County <br /> 4$00 West 57th Street Sioux Falls SD 57117 Minnehaha <br /> Mme of Chief Exer-Ufive cer of vrganizaGon (CEO) Daytime Phone number of CEO <br /> First Name Last Name <br /> Judith Ryan C05) 362- 3100 <br /> arrK o rgan¢atEan Treasurer Est Name �Y�� Phone Number of Treasurer <br /> First Name <br /> Dan HoYdhusen (60$ 362-3355 <br /> Type of Nonprofit organization <br /> Check the box below which best describes heck the box that indicates the type of proof attac�c�! ro this a�pEicati <br /> your organization y your organization: <br /> IRS leftr Inc exempR slams <br /> Q Fraternal � of good og ft Minriewa S Wry of Stake`s dfioe <br /> ❑ Veterans Q A dtiarW 00win9 You're an aWte Of a parent nonprvlk organ¢abon <br /> �Xl Religious <br /> [� <br /> other nonprofit 0�roa�previoushr sub��itled and on fie with the Cawribiirig Conbot Boat <br /> G4yj ling Promises Information <br /> Name of Establishment where gambling activity will be conducted <br /> Roseville Good Samaritan Center <br /> rDate(s) City State L'P Code County. <br /> 5 County Road B west Roseville MN 55113 Ramsey <br /> of activit�r {for raffles, indicate the date at the drawing) <br /> September 28 , 1998 <br /> Check the box or boxes which indicate the type of gambling acth►itY Your ¢ation will be conducting <br /> [] 'Bingo D Rafts D 'Peddlawt►eeks ED 10Pu11-tea CD 'TipbWr+ds <br /> *Equipment for these activities must be obtained from a licenstd distributor <br /> milli 1111MMEMMM-_ <br /> For Board Use Only <br /> Be sure the Local Unit of Government and the CEO of your oxgan¢ation sign D���tials of Specialist reverse side of this application. <br /> "MEMO <br />