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Minnesota Charitable Gambling Control Board LAWF'UL GAMBLING EXEMPTION <br />-Midwa�y Building <br />Room N475 Grig gs <br />FOR BOARD USE ONLY <br />1821 University Avenue <br />83 <br />St. Paul, M1\1 55104-33 <br />K-%N <br />111611,2) 642-05155 <br />Name of Premises here Activity Will Occur Date(sj of Activity, drawing1s) <br />St, Rose of Lima School Jars. 31 Y 1989 <br />Premises Address City State Zilp County - <br />21072 N01.1 iii ne Ave Roseville 13 lRamsey <br />-94 <br />penses <br />-qo Ex and <br />Market Value <br />Game Yes NO .-.Grioss Receipt Cost of Prizes Profit of Prizes <br />t 44 <br />Bingo X <br />4 <br />7 k jek <br />4V <br />Raf f liels <br />X <br />k. <br />rt <br />X <br />Paddlewheels <br />X <br />Tipboar,ds <br />Pull-Tabs A <br />X <br />Use of Profit Genierial School/Parl's elvenu # Benefit of Computer Education :Ln School 0 <br />mlibling Eq <br />3.. <br />et License No., <br />DiscribMior From W Go uipnnnit Acquired <br />o.._ <br />VN -,"4 <br />:4. <br />0 i9n, <br />I af f irm al hformati 'n udm 'ed to the IBla d is true, accor- I affirm all financial iInformation submitted to the Board iS <br />pij <br />ategr an gompl e tTaccurate, and complete,. <br />x.v-. <br />X <br />,qV <br />z <br />7T <br />:314 11— P. • 0000 <br />Chef E cutivebftliiceT signature Date Chief Executive Officer Signature <br />Date <br />Name of Local Governing Siody, (City or County) I Township Name (Must be notified when County is the approving bade) <br />Signan of IPlers,on Recei PIP1111 a "on <br />,.4.- , � VA"- ; rtl-c <br />Signature of IPeirson Receiving Application <br />Title Date Received Title, Gate <br />CG-000201 -01 (6/'817), 'White — Board Canary — Board returns to Organization to complete shaded areas. <br />Pink — Organization Gold — City or County <br />