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'.. "" , , I I -V M�innesota, Charitable Gaim,ng Control Board LAWFUL GAMBLING EXEI 1PTION • Room 1N475 Griggs-Midway B�u�ilding FOR BOARD USE ONLY 1 Un 8 iversity Avenue • 2 M - �83 33 St. Paull, �N 551,04 1612)642-0555 Narne of Premises Where Activity Will Occur Premises Address City, County, State. Zip Code, St. Rolse of. Lima Church Va[ue of Prizes I Expenses I Profit usoof'proft General. Parish Revenue: MAintenance of C%urch,, Utilities, Benefit of Religious 2 F�.: Education enefit of Ne,edy, Benefit of Sebool, Distributor From Whom Gambilingi Equipment Acquired Distributor's License No. N I affirm all formation submitted tothd IBoard, is true,, accu- I affirm alll financial information submitted to the Board is rate, a com a trine, , accurate and complete.- 4*-271-*87 iff --ew Date;, Chief f4ecutive, Offifterr'Signature Date ChW'Exiemft W'd Offk*r Sidnaturo--- 7- 4C0j46j,1WLE'DGMENT OF NOTIC LOCAL GOVERNING BODY I hereby, acknowledge receipt of a, copy of this application. By acknowledging receipt, I admit having been served with notice that this applicatio'n will be reviewed, by the C'habitable Gambling Control Board and will become effective 30 days from the date of receipt (noted below) by the City or Coulntyi unless a resolution of the local governing body is passed which specifi- cally, disallows such activity and a copy of that resoiution is received by the Charitable Gambling Control Board within 30 days of' the (below, noted date. CITY OR COUNTY TOWNSHIP Name of Lc ali overning Elc0004iity or Ciouinty) Township Name Must be notified when County is the approving body) Si, nature o Person kecef=gi Applicatla Signature of Person Receiving Application AL name= *:S�r ::: Titte Date Received' Date' Canary Board returns, to Organization 10 keep Gold — ity or, County