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Minnesota Charitable Gambiling, Control Board LAWFUL GAMBLING EXEMPTION <br />Room N4,715 Griggs-Midway Building <br />FOR BOARD USE ONLY <br />18,2111 University Avenue <br />St. Paul, MIN11 55104-3383 <br />(612) 642-10555 <br />INSTRUCTIONS: 1. Submit request for exemptiion at least. 60 days prior to the occasion. <br />2. When completing form),, do not complete shaded areas until after the activity. <br />Giive the gold coo 'to the City or County. Send the remaining copies to the Board. The copies will be returned <br />with an exemption number added to the foirim. When your activity is concluded; complete the financial <br />PLEASP TVP,F infInrmiqtinni Q 'i r7 ni ex n ri &2+m thin form inriiiiiiiiiiiii 4p% #6.oq. MiAd aft A4 . . .:&Lm aw iiiiiiiiii, f%j% A — - -- <br />. - - - -- -- 7r,711-MC r 01� <br />Type of OiVanizaium �V <br />0 Fraternal 0 Veterans <br />41mal 'i <br />0 Religion ^01ther Nonprofit Organization <br />Attach Droof Iof thlree veers Rxistance <br />NMS OfFrarni"s Where Activity Will Occur, <br />&eJ." <br />Premis" Adid"m <br />7&0 <br />4/1 <br />Game <br />yes <br />Bingol <br />"Ifles <br />Paddlewheels <br />Tip,biloarids <br />Pulllll -Ti a,bs <br />Use of Pratit <br />Distibutor From Whom Gambting, Equipment AcqujMd <br />I a,ffirm all information submifted tothei Board is true, <br />aicc rate, and colm liete., <br />iief Executive O11ff cer Sionature <br />It Othw NkmpmMOMmization, (Check Om aWi atwh proolot KM r ppofit,%tui <br />0 IRS Designation <br />0 Incorporate with Secretary of State <br />hiI Affilinifiies ^4 D-Nisodnir%* <br />LkId <br />swomil MV& WOMW <br />M"tatWa Ucerkm W <br />ll _44 <br />affirm all fina,nlcial information submitted to the and is true,, <br />accurate, and complete. <br />Q 7, <br />E71J <br />Date Ichief, r=6CUW" off�ow ftnatwei Dole <br />A(MA04i" <br />I h�erelby acknowledge I recielpt of a copy of this appl�ication. By acknowiledg�ing, receipt, I a,d�m�it having been served with notice thatthis <br />application will, be reviewed by the charitable Gambling Control Board and will! become effective 60 days from the date of receipt <br />(no,teld below) by, the City or County, unless a resolution of the, local g�overnin�g� body i's passed which specifically disallows such <br />activity and a copy of that resolution is, rIeceivied by the Charitable Gambling Control Boaird within 60 days of the below noted date. <br />PI 17V i's, 0 P V I I kIIII'i <br />Jill Ak <br />Sii_qnatuT4o1 P r5i Ro <br />4W <br />Tiiido I <br />Sjgn&tUt* of P&wn Receiving Appiicah-o—n <br />t.iii;U-uUWxU-u;e jef BIB) 'While — Board Canafy' — BOWd returns to organization to ompiate shadw arm <br />Fink — Organization, GKWd — 01y or, C4untyi <br />