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Minnesota Lawfull Gamblung <br />L volt <br />A &on for Autho *zaton for <br />(Rov., 4M93) 6Eke"mpn from Lawful Gambling License <br />F in <br />ill' this, unshadod' portions of Mis application for, examption and, <br />send it in, at least 45 days, Wore your gambling aicfivity� for processing. <br />Nani,e ddress , o <br />I dAif Or <br />an .9anization <br />­­ IOR BOARD USE ONLY <br />FEE 1-1 U iiii <br />[NIT DATE <br />40 �r)16 W ,_ <br />Organiz ]on Ni arm* <br />r, <br />currenUprevious license number <br />Curreniwious exempt nunimr <br />Cit /I t <br />L <br />Streel CU V. <br />Y <br />Ile <br />State Zip coft <br />A11V fiiiiii`� <br />County <br />all axeel�pazAer, <br />Chlet ExeWive Officer a Daytime Phone Nuffter <br />All 4;41 <br />Treasurer <br />Daytime Phorw Nu <br />W <br />6 tPOTC <br />yd <br />a.74 ai'itiz a., on <br />Check the box that indicates your proof of nonprofit <br />Check, the box below which Indicates your type of organization <br />attach <br />end a <br />status and attach a <br />Yof <br />opy of proof to tine application. <br />Frate mial <br />�e gn <br />IRS do gnaUio <br />C] Veiterians <br />af i <br />0 card U Of <br />standing from the Minnesota <br />Religious <br />1) <br />Sock 0 <br />ff c* <br />to's office <br />0 Other non-pri <br />Atifiliate, f parent <br />nonprofit organizafion (rhartar) <br />bra;iiiIbUng, -site - <br />mow, en ee�eeeeenweew�■w <br />Name lot she wtvirie scuivity witi take., Place <br />J# <br />C <br />WSW City TcOmship Stale Zip <br />Ra <br />code <br />ounty <br />N. e axh <br />e <br />Diate(s), of activity (for raffles. Indkiate, tie Idate of the drawing) <br />'65' bfGames,.-" <br />M n ic�n' al'R' rt <br />C% epp, <br />Market Vailui <br />I declare all in to r Iti I suDmittecf to Me <br />Gambling, Control Board Ifs rue, accurate, <br />and mimnlente., <br />of is true, accurale. - " complete. <br />W4- IV4'; 11 <br />Lj 4A <br />re <br />Chief Executive C1 "e Sig Date jChI4 Executivo 011i'tcS canatuiiis J6: <br />ry(t 414, gnatu <br />k now <br />i have mm !"d a cW► oi application. 'Tft Wplimlon will to reviewed by� the Gaftlft Wgrol Bowd &W will become eftedive 30 days from the date of <br />receipt, by ft cKy or county, unless �ft, locW Uft Oil pv9rinrnent passes a rosolution'to spedloally prohibit the actiVIty. A copy of that resolution must be 110tived <br />I <br />by, this Gambfing Control Eli wiNni 30 days of the disto filled In below. Cities of ft, fail clam (have 60 days In which to disallow the activity. <br />myoffturfly, —TTownship TownshiD iS <br />City of icounty, rwne <br />�d <br />Zi <br />7<7 <br />I erion mcei lnrg 111WWIon <br />Thile <br />This form willl be mafdo aivalllable <br />in aftlernative form (i■e., large <br />print, braille) upon requesi., <br />Towrtship name <br />Signature of person recemnig application <br />Date received JT111119 <br />Mail with $25 permit fee and copy of <br />proof of n,onprlof it status to: <br />Gambling Control, Board <br />1711 W, County Rd. B, Ste. 300 S. <br />Floseville, MN 55113 <br />Received <br />ID 0 <br />rganized <br />V <br />El unorganized* <br />0 <br />E] unincorporat <br />*4T,ach letter <br />White - Original <br />Yellow - Board returni, <br />Organization to complete <br />shaded areas <br />