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LG220 <br /> For Board Use Only <br /> Rev06/96 Minnesota Lawful Gambling Fee Paid <br /> II Application for Authorization for an check <br /> Exemption from Lawful Gambling License Initals <br /> Date Recd <br /> Organization Information <br /> ,rgisnization Name -- Previous lawful gambling exemption number <br /> J/ f e s� k/ / _ —,7- oG/ <br /> Street City' State Zip Code County <br /> S.g-c .2) k' 1 k, ) Air) ,_5-s-//. ` / ,�,7'4- <br /> Name of Chief Executive Officer of organization (CEO) Daytime Phone number of CEO <br /> First Name I Last Name <br /> p/// l✓� I /t' , IC/ // v/� �,3J--m. me of Organization Treasurer Daytime Phone Number of Treasurer <br /> First Name Last Name <br /> /f4 / , //t om/ Viz) 6,fi 4333 <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 /> iiiyour organization E Fraternal <br /> O Veterans <br /> by your organization: <br /> '{� IRS letter indicating income tax exempt status <br /> 0 Certificate of good standing from the Minnesota Secretary of State's office <br /> ,� <br /> QSi Religious 0 A charter showing you're an affiliate of a parent nonprofit organization <br /> El Other nonprofit Proof previously submitted and on file with the Gambling Control Board <br /> Gambling Premises Information <br /> i:amG of 4..a.ay..:a,ua.e where gambling activity :.. be conducted <br /> r 1, 7 1/ oF 27 „..4/✓A) (--MJ <br /> Street City / State Zip Code County <br /> 1J ,i emu- i //� --n •� `c7 <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> Mt / -7 <br /> Check tie boxor boxesfr <br /> ]— hich indicate the type of gambling activity your organization will be conducting <br /> 0 *Bingo (�Raffles 0 .Paddlewheels El 'Pull-tabs 0 'Tipboards <br /> *Equipment for these activities must be obtained from a licensed distributor <br /> III 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 /> / / _ <br />