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r <br /> LG220 For Board Use Only <br /> Rev06/96 Minnesota Lawful Gambling <br /> Application for Authorization for an Fee Paid <br /> Exemption from Lawful Gambling License Check# <br /> OInitals <br /> Date Recd_ <br /> Organization Information <br /> Organization Name Previous lawful gambling exemption number <br /> 1 1 \ILl''t31A- --each-ef cC Icc.htt) , 1:Y/(. C.c w e iq%a Av r h-ih-r4,1-4 <br /> Street City State Zip Code County <br /> i e)co �E S i-ve j- / W t% 0. i . IA c'FL . P_co.Ase.9 <br /> Name of Chief Executive Officer of organization (CEO) Daytime Phone number of CEO <br /> First Name Last Name <br /> Vcaw\ SC.11INnlic2— (1 2-) ipyi- Iu� cv 53t-iZ IE, <br /> Name of Organization Treasurer y First Name Last Name Daytime Phone Number of Treasurer <br /> bo.f..) Vieth h 84- ( Iz ) 3 - 0 Lt zv <br /> Type of Nonprofit Organization <br /> Check the box below which best describes Check the box that indicates the type of proof attached to this application <br /> your organization by your organization: <br /> 0 IRS letter indicating income tax exempt status <br /> ill ❑ Fraternal <br /> El Certificate of good standing from the Minnesota Secretary of State's office <br /> El Veterans <br /> ❑ Religious ❑A charter showing you're an affiliate of a parent nonprofit organization <br /> M Other nonprofit Er Proof previously submitted and on file with the Gambling Control Board <br /> Gambling Premises Information <br /> Name of Establishment where gambling activity will be conducted <br /> l f\"r el"CO'NCILizt. JChoi, t <br /> Street City State Zip Code County <br /> I Sr I�U0 l,-C'_u k5t -ice +-I ►� SS I i Z- 140,1V�y i <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> ❑ *Bingo 12I'Raffles ❑ *Paddlewheels 0 *Pull-tabs ❑ *Tipboards <br /> *Equipment for these activities must be obtained from a licensed distributor <br /> sure the Local Unit of Government and the CEO of your organization sign For Board Use Only <br /> e reverse side of this application. Date&Initials of Specialist <br /> / <br />