|
LG220 For Board Use Only
<br /> Rev06/95 Minnesota Lawful Gambling Fee Paid
<br /> Application for Authorization for an Check#
<br /> Exemption from Lawful Gambling License Initals
<br /> Date Reed
<br /> r �r'.ik��'a4�" a:i+�. u, sl: t P €';r £ � �� t f k V .. 5, Ph�Elr �; F9t.
<br /> tlat ..
<br /> t iii �! `. I-,3 VlI yl� r: a&°!IP Ilry •: �, -- y + - : `
<br /> Organization Information ,0k i ! 4 I� , K ,!,� ! y I�
<br /> Organization Name / Previous lawful gambling exemption number
<br /> glf,eC`/-/ oL f/ •,�oNA) /ie &/ /� A 6 o2/.5 1- /C�O - . •
<br /> Street City S ate Zip Code ounty
<br /> U_S— -b X24C 71) th/' /T, i ,V ,f i 3 /A K7/74.'zy
<br /> Name of Chief Executive Officer of organization (CEO) Daytime Phone number of CEO
<br /> Fi7lame I Last Name
<br /> / 7Lj) 1 62-
<br /> /e/e7/9,01/ (t/z) .1,5-k .g
<br /> Name of Organization Treasurer Fi Name Last Name Daytime Phone Number of Treasurer
<br /> Pil-fize/1/ I 1 r �/J ) 4_5-113.3
<br /> Type of Nonprofit Organization
<br /> N,1:::,,i1,,,,i,:!„,,11,!:::,,,,,,,,,,,,,,t,,.,k,,,,;,,f,,,,,,:•,,-,,,i-.i,i.,,,,,,,:•,,,:,;:i,f,:,,,,,:,•:,.,,,;,,,.:,!,,,:11,,,,.,,7,i:„,,,;„!,.,:,,:„.;,,,i,:,,,,,i::,.,,!,,:ii,„.,,,:. ,.:, ,,;.:.J::,„:.i.i.,,,,;::iii_.,,,i'fit:.,i,.",,:•,,-,,,,_,iit,;:i;ii,,i„,,,-.,„:,:,:,,,,, :„:,.--rc,',;=:.;,,i:,,,::,:,,:,::;,,,-,„,'1__,:
<br /> heck the box below which best describes Check the box that indicates the type of proof attached to this application
<br /> our organization by your organization:
<br /> SIRS letter indicating income tax exempt status
<br /> D Fraternal Etertificale of good standing from the Minnesota Secretary
<br /> Veterans of State's office
<br /> 0 DA charter showing you're an affiliate of a parent
<br /> 0 Religious onprofit organization
<br /> 0 Other nonprofit roof previously submitted and on file with the Gambling Control l
<br /> Board
<br /> 4*, It fi {N!1 €#MIS 4 2 S _ 5�
<br /> Gamblingy� Premises Information ° `
<br /> e�
<br /> I ;, y;
<br /> 5
<br /> Name of Establishment where gambling activity will be conducted
<br /> di ,i-e c ,f/ Sw/v /Xe- lf7/—
<br /> Street City / State Zip Code County
<br /> 1 S : ti.-D /iG4- /11 l-l) 4J -&1 &/ 7 /l% .. -s-/4 ` ✓ ._ex-z.
<br /> Date(s) of activity (for raffles, indicate the date of the drawing)
<br /> Check the box or boxe which indicate the type of gambling activity your organization will be conducting
<br /> D Bingo Raffles D Paddlewheels ❑ Pull-tabs D Tipboards
<br /> For Board Use Only
<br /> Be sure the Local Unit of Government and the CEO of your organization sign Date & Initials of Specialist
<br /> 111
<br /> the reverse side of this application. /
<br />
|