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����� �;E�� �
<br />Nlinrr�sa�,� LawFul Gaxnbling
<br />LC��I� A,�p����t�r�� for Exempt•Permit
<br />An exemptp�tmit mayi'aeissuedto a nqnp�Cs�"rtqt'��AixBtinrr
<br />c+or�siuctit�g fawFe€E gamblingac�iviiy Qn fiv� art'ewer clays, and
<br />awarding le�* than $50,000 i n Rraza� ¢urings a calendaryear.
<br />�rganization �ntormation
<br />Organization name
<br />� � ���_�L_�� 1 � � E�J � �'!►�
<br />�trae� � �, � ��, - --•
<br />r�a-rra af tiFrfaF��� p°rt�er ���E��
<br />F#at n� �a�{y�
<br />�i�r� ����
<br />..�.
<br />�yp� �� Mar�p��ft Q'r���i���i�fi
<br />�'ag� `! of2 2t05
<br />Fee $50 ��°����°�
<br />�����
<br />�FseckTJa.
<br />F�reviactslawful gamblingex;�tlrtptit���ti�rtt#�e�'
<br />� 5'.ate��ip Gc�de �ou�,�r
<br />� ��� �nnf
<br />Dayti me ph on e ttu[1'tb�+`
<br />Type of Clonpt�ftorganization (C�+eck one)
<br />a Fwi�arr� � Religious
<br />� �el�raa � Other rt�nprof�t organization
<br />a+�f,� �Dr48r af n4nplO�if Stdttts • dtt�C% a,:�ia,=f �ae� inatrv+ci�qt�]
<br />� Nop�rafft?��;rI�R r�� ,nr;��o� 4- �RF�IEB vi �� �arp�g a � ��E�t dr �m'L �r,e
<br />� Internal Revenue Service
<br />� Afflliate of�►�terlt, nonprofit organization (charter)
<br />QProof previously submitted and on � with the Gambling Cortt�'pE Board
<br />Gambling Premises Information
<br />Name of�srerrtis�swheregambling�<ativitywilEbe conducted(for �����,Is�tth�sit�.vsktes�tt�er�rawingw�+i�s�p1���
<br />� �[ �i � � �€�. �`� �h5 � �.►, r]+�_ . �..r� r��
<br />Addr�!ss(do notuse PQ box) � � �
<br />a�-� � 1 1�`�. �.1� c�. � �r� l � � , �� �.�. L-
<br />��f�} activ�fy(fqrraffles, indicatetttecfateofthedrawin�)
<br />�SI i4 �� _.��
<br />�ipCo��* Gou�h�
<br />C"",.a�""�! 3 �a. �. � � �
<br />��box orboxesthatindl�t�thetypeofgamblingactivityypU�organizationwillbe cand��it�g;
<br />� �����o � � 0 y�����e�e�rs � ��.T�� Q ����oa�ds
<br />"Gambling�ui�rrj�nkf�rrpuil-t�fis,t'spbc��r�is,pa�d4&�ruhe�f5,andb9r�gtr�bi[tgppaper, handcards, nr�bingoball
<br />6�i�C�ar� device) must Be obtained ��arrr a distributorl�ce»�ed by tl'r� G2�mblin� Control �p�;�d. '��find a licensed
<br />distributor, goto��nNgc�f.5f,�t�,�n,usandclickonListofLicensedL�P�tn"butnrs. Orcall�'[�9�FaG�
<br />form�t (i,e, large print, SraiSE�j k� tr�1e�1.
<br />i`h�infomlaEiar�re quested4nthisfoim(and
<br />�rqraf�M�meiie��ll be u�er�by th� G�mblir�g
<br />Contro# F�p�rr� (Bo�t�} to determine your
<br />qualifl�#kans fa be �nvatvec! in f�vvtulg�rr�€irtg
<br />���y�4��sinMinnesota. Yauhav�therFg�r�to
<br />��ae to supply �8 irff�rr�&t�ot� requested:
<br />however, ■ you refuse to supply Ehis
<br />information. the Board may not be abte to
<br />dst$rkn;n� your qualifications artd, as a
<br />����%Ru���, may ��f�€S Ga issue you a
<br />permit. If ya�► supply �he information
<br />requested, ����pw►Iib�abletopr�,s5�
<br />your ��ap#ication.
<br />Y OUf n � mv �� Y{SUCSI€Cf r�TtiZ9tlt11l1S tl�}�Y@
<br />and �ddresswflf b� p�.€�Sicirifc�rmatFOn when
<br />I�IC1�+ed�k�oBo �,Pff��fhYCFarrnal�
<br />1h3!}uu prr.u�d4 u�� ��nre{cdele ab�a! �o�;
<br />unii14he8oardF�x�cpc�rpes�� Whenthe
<br />Boardisx�-sy.��� ,si3afttieir�armakiati
<br />that You have provi� �a the �ss�rd 'sr► ifte
<br />�'21FR�j� �f' pG'T�L� �
<br />pub�i . If {�e Board doe� not issu� you a
<br />pesrn�, �A1ha Iri�r�un po� f�a�,�provided
<br />ir, vh�pr�aers:�F��^i�y $ra �� ��1'r�
<br />private. wi�i� }�te �xaention of v�ur narrta and
<br />�a�r �r�qrv;ali�w'� r.�rnr an� �ddr�ar, whlek
<br />wi1��?�i7public
<br />Pri�'�h� � e�o4t �°° � �lf��c anA' �n
<br />BoardwRt.r.. ••---�_ 1,' - ��--��. -,� ���
<br />�have �O`�� °� � ���'� �
<br />�',esota�nrn���„bc+e�.�; -�e
<br />-,�• - --
<br />NlilTites6mA�G+�+',�y Q.r,irrrl; il-� Mlnr.ipak3
<br />Commissionersoc��tlrr��,�eeg�, Finance:
<br />er�� .4evewue; 'ha �'flr•fiea�+la F��s L�duo
<br />+�IIC�'Gf. IItYJa!IaI arlh i'Ih/.mr�;��lle� $71���j
<br />��5��' ap�+-�+es: �+�?� pu�uert�s �.y
<br />��#vr.4C'Nr i'�dF.iduS��n� o$�r,C�ihet el•a
<br />�Ih' 8,s`�Orir.�d �y RIAIa nr �el�,l4e�r
<br />i�heua ee�e� ro n�o ��e,aUun.lr►df,�'�I��s
<br />�r.d yp�rrQ9� i4f 3i1T�� 17�' {C f�� CR�9r
<br />��+0�0� � rlA14���I�rir1� d��
<br />aharPhk� N4E� we� iMerr �ti enyon� whJt
<br />yaurr,�nsent,
<br />�, �
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