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innesow Charitable Gamblin trol Board
<br />LAWFUL GAMBLING EXEMPTION
<br />M
<br />Roarn N475 Griggs-Midw,ay Building
<br />FOR BOARD USE ONLY
<br />1821 University Avenuie
<br />St. Paul, MIN 515104 3383
<br />-0555
<br />r.
<br />(612)642
<br />INSTRUCTIONS.-I 1. Submit reque t for exemption at least 30 days prior to the occasion.
<br />Raffles 1 X
<br />M
<br />T'ipboa,rds
<br />PulkTabs
<br />�Use of' Profit.
<br />a e e
<br />e iim,l.-a ideq ipmen
<br />Fund ser,-,toi .,Olffs t��expens,s f or-'ic—t, en U t
<br />Distributor iF:ro,m Whom Gamblinig Equipmeryt Acquired Distributor S L"cense No.
<br />Non,le
<br />I affirm all information submititied to the Board is true, accu- I alff irm a�ll financial information submitted to the Board 'I s
<br />rate, and complete. truei,' aiccurailte, and compl ete.
<br />MI
<br />Chilef Executive Off iceir Silginatuire Date
<br />ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I hereby acknowledge receipt of a copy of th�is application. By, acknowledging receipt, I admit having been served with notice
<br />that this appilliciation wil! be reviewed by the Charitable Gambling Control Board and will become effective 30 days from the
<br />date of receipt (noted blel�ow') by the C'ity or County, unless a resolution of the local governing body is passed which specifi-
<br />cally disallows such activity and a copy oif that resolution is received by the Charitable Gambling Control Board within 30
<br />days of the below noted date.
<br />CITY OR COUNTY TOVVNSHIP
<br />Name of' Local Governing Body (City or county) bwnship �Name (Must be notitied when County is the approving body)
<br />Rosevi'lle
<br />Signature of Person Receiving Application
<br />Title Date Received
<br />CG-010020-01 14186) Whim — Board Canar,y — Board returns to Organization to keep
<br />Organization, Giold — City or County
<br />IM I =741 I In
<br />Irganlization Name,
<br />Riolsev,ille
<br />A,riea Youth Hoickey Assoc-l'ation, Inc. SPILMS A
<br />A,dd�ress
<br />1,1,1,4 Woodhi,11 Drive
<br />IIM III
<br />Chieif Executive Off icer"ls Narne !Plhoinei, Number Manager's Name
<br />Mike Graiiish �613 61— 514 8 0 Jonathan Ew Wheaton •
<br />Type of organization,
<br />III
<br />0 Fraternal
<br />CJ Veterans
<br />■ Religion
<br />[X Othe on prof it 0 rganization
<br />lip
<br />Name of Premises Wheire Activity Will Occur
<br />Roseville
<br />VFW Poist 7555
<br />Prernises A,dd�ress
<br />1,14,51 Woodh,il,l Driver Roseville, MN__. 55113
<br />Val�ue of Pirliz, -Expenses
<br />G.ross Receipts.,.,-.., les L
<br />Raffles 1 X
<br />M
<br />T'ipboa,rds
<br />PulkTabs
<br />�Use of' Profit.
<br />a e e
<br />e iim,l.-a ideq ipmen
<br />Fund ser,-,toi .,Olffs t��expens,s f or-'ic—t, en U t
<br />Distributor iF:ro,m Whom Gamblinig Equipmeryt Acquired Distributor S L"cense No.
<br />Non,le
<br />I affirm all information submititied to the Board is true, accu- I alff irm a�ll financial information submitted to the Board 'I s
<br />rate, and complete. truei,' aiccurailte, and compl ete.
<br />MI
<br />Chilef Executive Off iceir Silginatuire Date
<br />ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY
<br />I hereby acknowledge receipt of a copy of th�is application. By, acknowledging receipt, I admit having been served with notice
<br />that this appilliciation wil! be reviewed by the Charitable Gambling Control Board and will become effective 30 days from the
<br />date of receipt (noted blel�ow') by the C'ity or County, unless a resolution of the local governing body is passed which specifi-
<br />cally disallows such activity and a copy oif that resolution is received by the Charitable Gambling Control Board within 30
<br />days of the below noted date.
<br />CITY OR COUNTY TOVVNSHIP
<br />Name of' Local Governing Body (City or county) bwnship �Name (Must be notitied when County is the approving body)
<br />Rosevi'lle
<br />Signature of Person Receiving Application
<br />Title Date Received
<br />CG-010020-01 14186) Whim — Board Canar,y — Board returns to Organization to keep
<br />Organization, Giold — City or County
<br />
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