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Winnesota Lau&l Gambling FOR BOARD USE ONLY <br /> FEE �HK� <br /> L plication for Authorization four FEE SATE <br /> . 3 from a Gambling License <br /> R#i7 Me m a �e of 016*0686M for ammo on and <br /> and 9 in at t da bakre your ac 'ty for processing: <br /> ad <br /> d On <br /> ar e#lon cum a lk*n"nunftr CurmrdVevbw sxemo number:2 71 9'4 <br /> ��� <br /> Tf City sty$ �e CCU •A//V <br /> ROOM 1300 :200.s A/0 02.1 <br /> Chief�lve Of�aer Dayttrne Orono Number Tr rar, Daytime phone Number <br /> ,- <br /> -3 qL1 5-2.2 cY I j I A 6 A)I�j Ali Ile (61-x) P3 Y V 7 <br /> .......... <br /> .. .. ............. .. <br /> r •• -- - <br /> NI.-j, Z N.,- <br /> • - -.- _X.-_:X:,L�� <br /> fit Q <br /> _ Check the box that tnclleates your proof of nonprofit <br /> Check the box below which indicates your W"of or rrl�ation status and attach a copy of#ha proof to t application. <br /> fraternal ❑ IRS designation <br /> [� Veterans � CerNmOon of d king fr�an the Minnesota <br /> El �li�We Secretary of State's office <br /> 0 �lher non-profit � Affiliate of�;�nt nonprofit or+�an�adon(charer; <br /> Co <br /> .. ., : _ -- --- <br /> Vdihbli Sift <br /> •.��•��•.•.r MCI.iY...•..�ti•i�.•.i../�MiYMi ti._1 7. <br /> Nafris of sac dives.W11 t 14) <br /> e.565 t L� Yl `�J- COUN�y <br /> M a dp&G.W -P 0 -Town* SIW* Zip A10 L/ / Z. d95 MN <br /> (s)ai adtoty raffles,irrdic�.ate-the dais of the drawirg) <br /> t'1L -- <br /> Ift <br /> '! aIU <br /> - = lkat a�fi <br /> -- <br /> - = l anai <br /> ri ���li�io � <br /> 1tt. <br /> Gmn*s) <br /> _ <br /> ::I cash <br /> ....Bingo .. . ............. <br /> ... ..... ... ....... <br /> . <br /> f <br /> Raffles <br /> f <br /> Paddlewheels <br /> .. . ......... ....... <br /> Ti <br /> s <br /> .......... ................ <br /> Pull-tabs .. - - ... ............. <br /> Iram.wr�. =vas purl _ ::f:•:_.. <br /> 22 <br /> t e <br /> I declare all information submitted to <br /> -- _. <br /> tat <br /> Gambling t <br /> complete. .......... <br /> and <br /> Mew"all tine j6W irdorrrr ikm a6�it#ed to: i9a ling Co"01 <br /> Wwd is true.amra*e.w d mmiste. <br /> _ ..... _ -- <br /> Chief Executive otlfcees Bignaturs We 01of Easdati�6f%"r%P1jr�t�rs <br /> _Xy <br /> i - ftm0ftt­- .......... <br /> - <br /> I have�d a copy of H*application. This eppl"im Wil be rgviewsd the�lirg r"Board and w4l bey stfsci 30 days from the data Of <br /> receipt by the t or courty,Unisss tie local unit of governm errl passes a resokrtion to spol oWly pr ll the activ , A copy of that resolution fust b8 rsdotved <br /> by ft Corrtral Board wKNn 30 days of the d filled in below. CItise of the fii W dam have to In%NM to disallow the actt tty. <br /> Chy or County Township Township is <br /> CRY Of ovum Township name E]organized <br /> (001�or / 616 1/�, - ❑I�rlorganiz * <br /> C Irmia sr r~raoelvir'r�sppli ion Biprw�ture of per$an receF�irr�spplfcatfon El unin rporl�t + <br /> T1W Date received Tide Dais Re�ived Attach letter <br /> .000 /0 ej 7 <br /> Thin f url will b�mad available <br /> railable Mail with 5 permit fee and copy of Whhe-Original <br /> in alternative format(i.e large pmof of nonprofit sWua W. Yellow!Board returns to <br /> print,braille)upon requ es#. Gambling Control Boar! Organization to complete <br /> 1711 W.County Rd. B, Ste.300 S. shaded areas <br /> Rosevilla,MN 55113 <br />