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r,X-72jWl Mimmewta Lawful Gambling <br />'Renuest to Conduct <br />a <br />Unlicensed Bingo or Raffle <br />ans&ucdons on back of diisfonrYL) <br />�#Fdv-r-r G 4 VA � q q 1 '11 'ITMEMi I- f-1±1 <br />Type, of organization (check one): 01, Fraternal C3 Religious ;'veteran C1 Other nonpmfit organization <br />Number of acWe members, 4 :!? <br />,Z "beam in existence <br />B.ngo <br />-O-Crw Koca". <br />VARMAN <br />Mack one. Indkale state fak fair, or CiVic' cWebraltion if appropriate. <br />If, <br />* The b1ingo will be oonducted i*n oonnecSon with a: C3 county fair C] state, f C3 civic ce1ebradon <br />* e bingo will be, one of, four or fewer bingo events the organization will hold this year. <br />ate e) of birnigoi event <br />How many, times has your organization held <br />How many conselcubve, days will bingo be played? a bing�o event in the current calendar year? <br />How will the binigo profits be, used? <br />Name of person in charge of bin i o Phone ( I <br />MO <br />Total market vaiue ■ raffle prizes $ <br />Dates of raffle &awing aeAiz <br />How 'iilll the raffle profits be used? <br />Name of person in charge of raffle <br />rlhief executive offl,cer's signature <br />The informailtion pmvidad above is compiete anid'accurate to the best of my knowledge. <br />chief exemove, Officees, Date Cgs; ji??i <br />;5 <br />end t` compieted request' form, to <br />De'part,ment of Gaming - Gambling Control Division <br />Mail Station 33,15 <br />St. Paul, MII N 551A&MIS <br />N approved, your request, will be returned to you to post at your bingo or raffle event. <br />n <br />c ingo o- <br />1, Mton to a U611' e nsed B* r'Raffl <br />.......... <br />Your req"Usat to du an unilansed bingo raff le ha been <br />roved' <br />PoSt thils authorizatio 'n 'at your <br />n 90.0t rsff Is OvOnt <br />DoW <br />Gambling _fGamnig <br />pt mbling, Control Divis ion De 0 <br />