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ji a a FOR BOARD USE ONLY <br />INS'TRUCTIONS: 17 Submit request for exemption at least 30 days prior to the occasion <br />Name oil Plrem,ises Where Activity, Will Occur <br />Rosevil,lie VFW Post <br />Premises Add�r,ess <br />Gamies Yes No <br />Bingo x <br />"I-iff les x <br />Paddlewheels x <br />eville, MN 55113 <br />ross Receipt mes <br />Gs Value of PH <br />RM s, *3 � M <br />Tipboards <br />x <br />Plull-Tabis <br />x <br />Use of Profit <br />,Fund, rad, sex to, offs expenses for, ic.6—t-i-me and'equipment <br />- <br />Distributor From Whom, Gambling Equipment Acquired <br />Distributor's, License No. <br />None <br />II affirm alll information submitted to the Board is true,, accu- I affirm all- financial information submitted to the Board IS1 <br />�rate, and complete. truiel, "accurate, and complete. <br />7MdT-Z-- <br />Chiief Executive Officer Signature Date Chief Executive Officer Signature Date <br />ACKNOW'L,EDGMN�T OF NOTICE BY LOCAL GOVERNING BODY <br />I hereby acknowledge reiceipt of al copy of this application. By acknowledlging recelipt, I admit having been served with notice <br />that this application will Ibe rieviewed by the Charitable Gambling Control Board and will become effective 30 days from the <br />I oI <br />date of receipt ((noted below�) by the City or County, unless a res i ution of the Vocal governing body is passed which specifi- <br />icallly, disallows such activity and a copy lof that resolution is received by the Charitable Gambling Control Board within 30 <br />days of the bielow noted dlate., <br />CITY OR COUNTY TOWNSHIP <br />Narne of Loicall Governing Body (city or counto <br />Townshi p Narne (Must be notified when County is the approving body) <br />Roseville <br />nature of Persona Reiceivin8iggation Signature of Person Receiving Application <br />Title Date Rleceived Title Date <br />(L <br />CG-001020-01 (41M White — Board Canary — Board returns, to Organization to keep <br />Pink — Organization Gold — City or County <br />