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Minnesota Charitable Gambling Control Board LAWFUL, GAMBLING EXEMPTION <br />Rolom N1475 Griggs-Midway Building <br />FOR BOARD USE ONLY <br />1821 Universi`w Avenue <br />-3383 <br />St. Paul, MN 55104 <br />(1612) 642-01555 <br />INSTRUCTIONS: 1. Submit request for exemption at least 301 day's prior to the occasion. <br />4, <br />y .0 01 <br />of Prizes <br />Xpe <br />nses a <br />rket Value <br />ec,61 <br />A st of Game Ye s No �r��� e"Col Prize' <br />Bingo X <br />. . ............ .7 <br />W 4 <br />aiff l�es X 14 <br />44 <br />X <br />7. <br />P adidliewheels <br />.1 . 61, <br />t <br />Mpboards X " r'�.2n� � � m }'�� F N <br />. . . . . . . . . . . <br />4- <br />Pull-Tabs X �wr <br />Jw <br />Use of Profit <br />General ooil/Parish Revenue ,1r. Benefit of Computer Education In School,, <br />WI <br />Distributorrs License NO. <br />ee ibutor FrM libling Eq <br />. . . . . . . . . . . . . . <br />I affir 11 infer ati in, submitted to Board is true.. accor- I affirm all f inancial inif or ation submitted to the Board is <br />1 4% <br />ate n coll �nei t acicur6te,, and complete. <br />• AP <br />R& <br />/Z <br />W <br />Chie)rgxecdtivev Officer Signature -it k. Gate Chlef Executive Officer Signature Date <br />AUI�OWLEDGEMENT O;'F NOT"CE BYLOCAL GOVERNING BODY <br />'h�erebly acknowledigie receipt of a copy of this application. By acknowledging receipt, I admit having been served with notic-w <br />Narne of Local Governing Body (City, or Couinty) Township Larne (Must be notified when County is the approving body) <br />re of Person Releiviing �i�Ppficaitioni I Signature of Pierson Receiving Application <br />A, <br />Title Date Received <br />CG-(010020-01 16187) 'NSW hiite — Board Canary — Board returns to Organization to complete shaded areas. <br />eink — Olirgainizatwi Gold — City or County <br />MR <br />