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For Board Use only <br /> Paid <br /> Minnesota Lawful Gambling Fee Fee P id <br /> Application for Exempt Permit LG220 Initials { <br /> Received <br /> Organization information <br /> Organization name <br /> Previous lawful gambling exemption numbe <br /> Roseville Volunteer Fire Department Auxi 1 iar�r Inc. <br /> Street <br /> State/Zip Code County <br /> pity <br /> 2701 No. Lexington Avenue Roseville �•ir 1 I Rates e y <br /> Name of chief execrative officer(CEO) of organization Daytime phone number of <br /> First name Last name CEO: ( 651 490-2.300 <br /> Richard Forliti Y) 490-0179 <br /> Name of teasu rer of organ ization Daytime phone number of <br /> First name Last Warne treasurer: ( 651 4 9 0-.2. 0 0 <br /> 'ferry hagner <br /> Type of Nonprofit organization <br /> Check the box that best describes your organization <br /> 0 Fraternal Ej Religious <br /> F-1 Veteran EE other nonprofit organization <br /> Check the <br /> box that indicates the type of proof your organization attached to this application'. <br /> [I IRS latter indicating income tax exempt status <br /> El Certificate of Good Standing from the Minnesota Secretary of State's Office <br /> A charter showing you are an affiliate of a parent nonprofit organization <br /> proof p reviou sly submitted and on file with the Gambling Control Board <br /> Gambling Premises information <br /> where gambling activity will be conducted(for raffles, list the site where the drawing will take place) <br /> Marne of premises � � <br /> Fire Station #1 ::1 <br /> box) city State/Zip Code County <br /> use <br /> Address(do not <br /> 2701 No. Lexington Ave <br /> Roseville NIN 55113 Ramsey <br /> Date(s)of activity(for raffles, indicate the date of the drawing) <br /> October 4, 1998 <br /> EMEEMEMEEMMEWM Check the box <br /> or boxes that indicate the type of gambling activity your organization will be conducting. <br /> • *paddlewheels *pail-Tabs I D'�'Tipboards <br /> M Bingo � Raffles <br /> *Equipment for these activities must be obtained from a licensed distributor. <br /> This form will be made available in alternative format(i.e. large print, Braille) upon request. <br /> The information requested on this fora will become public information when received by the Board*and will be used to determine <br /> your compliance fiance with Minnesota statutes and rules governing lawful gambling activities. If <br /> Page 1 of 2 <br /> 3/98 <br />