Laserfiche WebLink
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 lnitals <br /> Date Read <br /> Organ`izatron Information <br /> Organizationrg Name �// Previous lawful gambling exemption number <br /> e446 e/-7 Oic ,.}/ �ak� lie &disi ,(-k Z/ J --n -vU5- <br /> Street City 7 S ate Zip Code County <br /> fJs b me A1'a/, e/61/a/11 ni 515-//2 440st-a <br /> Name of Chief Executive Officer of organization (CEO) Daytime Phone number of CEO <br /> First Name Last Name <br /> aefele.4 6E/c/A7/1.i (6/Z) 6 5-JIfJ . <br /> Name of Organization Treasurer Firstame Last Name Daytime Phone Number of Treasurer <br /> PATTRea /I G ee)i E4, ( ) �;d r9‘ <br /> 5s4 '`r x•x <br /> e of No T n rofit Or anizatron <br /> eck the box below which best describes `Check the box that indicates the type of proof attached to this application <br /> our organization <br /> 0 Fraternal <br /> 0 Veterans <br /> by your organization: <br /> [,SIRS letter indicating income tax exempt status <br /> D Certificate of good standing from the Minnesota Secretary <br /> of State's office <br /> DA charter showing you're an affiliate of a parent <br /> [Religious onprofit organization <br /> 0 Other nonprofitEIWO4roof previously submitted and on file with the Gambling Control <br /> Board <br /> Gambling Premises information { <br /> Name of Establishment where gambling activity will be conducted <br /> 1.9 ,:,e4.1)-6 no ( ire a) /v�`v,gE/6,9-/--e/J Iry .5s//. - ,-,�L-11 <br /> Street City State Zip Code County <br /> <--r;..,P1 45- /9 ys <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> Check he box or boxes which indicate the type of gambling activity your organization will be conducting <br /> Bingo CO Raffles 0 Paddlewheels pa Pull-tabs 0 Tipboards <br /> • <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 /> the reverse side of this application. <br />