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Minnesotia Charitable Gambling Control Board LAWFUL GAMBLING EXEMPTION <br />.ell <br />:l <br />Widway, Build'ing <br />Room N1476 Griggs FOR BOARD USE ONLY <br />1821, Univiersity Avenue <br />St. Plaull, M�N 55,1104-3383 <br />(61 2) 642-0555 <br />• WIM rm <br />Address <br />1114 Wiciodhill Drive, <br />................. <br />Chief �Exeilcillutive of ficeir's Name, Phone Number Managers Narne, <br />Mike �Gralish 6361-5480 E. Wheaton <br />#_ <br />Type of Organization 05 <br />E] Fraternal 0 Veterans <br />El Religion M Other N�onpiriofit Organization <br />11 AP ell <br />Al Gross Reteipts.. Va�lue of Prizes Expenses <br />I '_ ffies <br />K4 <br />Paddlewheels X <br />Tipboards <br />X <br />Distributor From Whom Gambling riquipment Acq,uired <br />None <br />I affirm all, fl-nancial information submitted to the Board is <br />true,. accurate.. and complete. <br />K M M. = 9 M TITTI 1. <br />- i itted to, the 13oara is true, accu- <br />- af'firm all informatilo n subm <br />.7atie and complete. <br />Date Iva ofricer Signature Date <br />Mmer,utive officei,r Signature Chlef Execut <br />4CKNOWLEDGMENT OF NOTICE BIY LOCAL GOVERNING BODY <br />Nlame of Local ICloverni nigi Siody (City or Courity) olw,nshiip Name JAA UST De 1­10111 1UU wwien county is ine appf uvinu UVUY) <br />'I <br />Roisev ill <br />e, <br />-natuire of P11 son Rem I v i pipliciation <br />14 811A <br />......... Date Receiv <br />Title A&S T�UAACS <br />Signature of IPerson Heceiving Application <br />IM <br />Canary, — B�oard returns to rgnization to keep <br />CG-00020-101 (4186) White -- Board Gold — City or, County Oa <br />Pink ­ organization <br />