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01 1111 <br />&1 <br />minnesota Charitable Gal mbling Control Board LAW'FUIL GAMBLING EXEMPTION <br />Riolorin N�475 Griggs-Mlidway Building <br />1821 University Avenue <br />FOR BOARD USE ONLY <br />Sit. Paul, NIN 515,1014-33,83 <br />(612) 6142-0555 <br />INSTRUCTIONS.: 1. Submit request for exemption at least 30 days prior to the occasion. <br />2,. When com plletinig, form, do not complete shaded areas, until after the activity. <br />3. Givie the gold clopy to the City or County., Send the re�miaining copies to the Board. The copies will be <br />returned wlith an, exemption number added to, the form. When your activity is concluded; complete <br />PLEASE TYPE <br />the f iniancial information, sign and date thie form, and return to the Board within 30 days. <br />ot nizatuo ho ame <br />-- <br />Number of Members <br />License Number (if currently or previousiy <br />Ul <br />licensed) and/or permit number. <br />Addiress, <br />State <br />Zip <br />Coon <br />Chie LEI=utive'Offic r'sNerne <br />rr I <br />Phone <br />Mainianeir" lame <br />Phone Number -u- <br />011 if '10 1, /4AJd <br />('412MI 0i <br />A%JCLtL-,f con <br />jjw & <br />Type of Orga4ziatfl',oin <br />El Fraternal <br />0 Vetierans <br />If' other Nonprofit Organization lCheck One and attach proof of nonpmfit statusi- <br />EJ IIRS Designation <br />M Refi gion <br />20thier Nioinpirof it Organization <br />El Incorporate ❑with secretary of State <br />Attach proof of <br />three years existence. <br />A%Sffi I i alte, of Parent Nonprofit 0 rg a n i zati o n <br />N=s WheriaACtiVility ill Occur <br />Date(s) of Activity. drig(s) <br />;4^J;( Its LAr toi <br />PrAntses �AddWss <br />Paddlewhileels <br />Tipboards, <br />Pull-Tabsi <br />i IT. . ;&A -iii 7 C* <br />T" <br />• <br />7! <br />M"ri T! <br />I af f irm, a 11 inf oirmati <br />