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"table Gambling Control Board <br />�Minn�esota Chan <br />9. <br />Room N1475 Griggs-Mildway, Building <br />1821 Ulniversit�y Avenue <br />Sit. Paul, MN 56104-3383 <br />Ile, <br />(511 ) 642 -0555 <br />INSTRUCTIONS: <br />LAWFUL GAMBLING EXEMPTION <br />FOR BOAAD USE ONLY <br />T., Su�bimit request for exemption at least 60 days prior to, the occasion. <br />21. When completing form, do not complete, shaded areas until after the activity. <br />31. Give the giolid copy to the City or County. Send the remaining copies to the Board, The copies will be returned <br />with an exemption numnber added to the form., When your activity is concluded; complete the financial <br />information, siqri and data the form- and raturn M thp- Rn,Ard within qn fcmu,& <br />Sto Roise of Lima SehnnlL /Chnrn-h <br />MEEK M92kdo r; m <br />%FFffii11441i PW 9141101fro <br />Fr. Patrick i Rvan <br />0 <br />Fraternal 1:1 Veterans <br />1k Religion 0 Othier I Nonprofit Organization <br />Attach proof of three years existence <br />St. Rose of Lea See-hirtini <br />ff -milap <br />No,. Rgv-,1i-;,e <br />UCenBe Number (it currently or prgvioU* <br />licensed) andlor permit numbw. <br />Phone NUmber <br />4, i P , 61LC;.0-22,V <br />lir I Li inrenprofit urgmization (,heck one and aI proof of nonprofit stab* <br />E) IRS Designation <br />E) Incorporate withl Secretary of State <br />D Affiliate of Parenit Noinr)rofit Oraianization <br />i'chool and Religious Education, programsil and activities <br />Dat%3) of Acbvity, Dmwing(o <br />April 30, 19H <br />Market Value <br />of Prizes <br />4 j <br />4i <br />A <br />Dili <br />q Equipment AcquirW [N3trit;trtoft uc�� <br />�k <br />.Vt.' It I'L2 <br />Chief Executive Officer Signature, <br />5 <br />0 jF <br />l,o ]Board is true, <br />fit Ell .10 <br />7, <br />C) <br />White — Board <br />CRnary --, %arrl rotorni,; tn OrfinniFption to rr)mniplp thafipei Prpqc <br />