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01 <br />Type of,Noln-profiti Organmadon <br />Years in existence.5i 0 Attach proof of three-years or more, of exi"Stence. Number of active members <br />__ IFraterinal S-Refigious ID Veterans I E) Other non-prof it <br />ff you cheocked' I box for other nonprofit, lcheec k one of the followil ainlid attach proof of nonprofit status <br />[I IRS designation C1, Incorporated with Secretary of State El Affiliate of parent nonprofit organization (charter) <br />GambUng Slitle! <br />IName lot slite where activity will. take P a <br />Street city ate Zip code Cotinty <br />,.,I - 4 (,z Q U ---� 1 1 0,09, -14) k 1 , _ - <br />Q I _� 1 ) I/]* _,,� A:�J_�Lxi I/,, /I I X 1.11 <br />Date(s) of actiVity <br />01 <br />1 <br />Tppes of Games <br />Financial Report °, <br />Gamis Yes NI o <br />Grow 1;*s <br />Expenses, Inctuding <br />Not pmllft. <br />Ma*m Value <br />Coo of Prins <br />of Prbns.! J <br />Bingo E] R, <br />.s <br />IRaff Jes r-T <br />Pladdlewhelels <br />T'ipboa,rds 0 <br />V, 7 <br />Pull-tabs D i, <br />4 <br />H Will protit, be Iusedl: <br />Distributor from who gambfing equpment purchased..',., <br />a2cl (A ci 00 <br />%Z <br />ifi <br />Disufttors, fimse numil1w. " <br />berI <br />4 " <br />.... .. ....... ... .......... <br />I dedare a# informafian submitted to the Depar&nen,t of RevenLie I decAre SW i7ft=B&M subm*W to Me I O(Re <br />iS t accura te. and complete <br />Vw,,, a=r8le,' aw comp <br />i niui <br />_Z <br />wit <br />dhief executive o,fficerks sia'In to il6 <br />date Chief execurfive officers signature Date <br />Local Government Acknowledgement <br />I hav'e received a copy of this applicad'on. This applicabon will be reviewed by three Department of Revenue and will become effecfive 30 days <br />from the, date of receipt by the city or county,, unless the local govemmen't passes a resolution to specifi cally prohibit the activity. A copy of that <br />resolution must be received by the Department <br />of Revenue within 30 days of the, date filled in below, <br />City or It unty <br />ity lor county <br />a 11 1 SU) f <br />ignature olf person recl&ivit M On' 0 <br />_dI <br />We* — Howd <br />l ­ IQg Woolacni <br />YodIllow ­ l irak,rmr i 62 Origant=Ion, to <br />C014"1101 Shi Bowl W601S <br />cla"I - Oily 'or it <br />�Diate rea i <br />'Township <br />ICT 111141trIll <br />gniatulre lot person receiving app <br />ifle <br />Mail this ill pplicatlion to,: <br />Department of Revenue — Gaming Division <br />Mail Station 33,15 <br />St. Paul, MN 55,14,61-3315 <br />