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Nam, of Premises Where Acfivity Will Occur <br />Vi Hrw <br />Minnesiota, Cha,rl <br />itable, Gambling Control <br />B�oa�rd LAWFUL GAMBLING EXEMPTION <br />Room N1 475 GriggswNlidway B�uilhd'ing <br />I <br />FOR BOARD USE ONLY <br />• <br />1821 Uiiiversi4 Avenue, <br />7r% I- <br />Prom ises Address, <br />St. Pau�l, Ni 55104-3383 <br />Y., <br />(611�2)16412-0555 <br />State Zip <br />113 <br />Cou nty <br />:5 <br />INST'RUCTIlONlS: <br />1. Submit requiest for exemption at least 60 days prior to the occasion. <br />2. When completi�ng form, do, nlot <br />complete shaded areas until, after the activity. <br />3. Clive the g.1old, copy, to the City or o,uinty. Send the remaining copies to the Board. The copies will be returned <br />with an exemption n�um,bler added to the form., When your activity is concluded; complete the financial <br />PLEASE TYPE <br />information, sign and date the <br />form,, and return to the Board within 30 days. <br />izabon Name, <br />14to A <br />Nee <br />Number of Members <br />License, Number (it c=ly or prftiousiy <br />licensed) andiof Permit nufrity. <br />0 61le �tj 11 <br />n i orTa r ► n <br />of Ptizes <br />(01 V <br />JVo d e. n .5e.CL <br />Address <br />liq <br />&4 <br />000":5 41/1 d' <br />cit► <br />state Ziip <br />13 <br />cc-unty <br />ni 5 e <br />Chief Exec uWe Ofter's Name <br />U-66q Lumian <br />Phone Number <br />Raffles <br />MI an Name <br />Phone Number <br />L 19) � 33- 7,967 <br />T)" of Orpnuandrt <br />it C*w Nooprofit Orpniiin*m (Chec*_0_1ne and atowh proof of nonproM sftWa]� <br />13, Fra,temal <br />0 Veterans <br />Paddlewheels <br />0 IRS Designation <br />El Relilgion <br />XOther Nonprofit Organization <br />0 Incorporate with Secretary of State <br />Attach proof of three <br />years existence <br />[3 affiliate <br />1 of Parent Nlonprofit Organization <br />Nam, of Premises Where Acfivity Will Occur <br />Vi Hrw <br />Date(s) of .vq. Drawing(sj <br />I <br />7r% I- <br />Prom ises Address, <br />cii tv <br />01.5 av V'11 <br />State Zip <br />113 <br />Cou nty <br />:5 <br />Expenses <br />Market Value, <br />,Galme, <br />Yes, <br />Nee <br />Gross Receipts <br />Cost offftles <br />Profit <br />of Ptizes <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipbola,rds, <br />V000F <br />Pull-Tabs <br />V/ <br />Us* of pimfit . <br />Distributor, From' loom Gambling Equipment Acquired I Di9tfi1bU_t_0esLkM_"eNM <br />I Affirm all informatilon, submitted to the Board is true, I affirm, all financial inf'orma,tion submitted to the and is true, <br />accurate, and comp�letel. accurate, and complete. <br />Chietixecua—ivie ffice"rSignaluire <br />bale Chief Executive Offii cer Siglnature onto <br />1014per JeC61v1pg_APP11y11qn ISIgnature o ca <br />l Person Receiving ApplitLon <br />.Is+ <br />While — Board <br />Pink — OrWizabon <br />U <br />T'iflle <br />Canary — &mrd returns to OrganwWon to compleft shaded urea. <br />Gold — Ciity, or Counly <br />Date Received <br />